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Nephrology Notes Review - Passmedicine 2012
Nephrology Notes Review - Passmedicine 2012
ADPKD
ARPKD
Alport's syndrome
Amyloidosis: types
Cholesterol embolisation
Ciclosporin
Erythropoietin
Fanconi syndrome
Glomerulonephritides
Goodpasture's syndrome
Haematuria
Henoch-Schonlein purpura
Hyperkalaemia: management
IgA nephropathy
Membranous glomerulonephritis
Mesangiocapillary glomerulonephritis
Nephrotic syndrome
Papillary necrosis
Plasma exchange
Retroperitoneal fibrosis
Rhabdomyolysis
Sterile pyuria
Tuberous sclerosis
Wegener's granulomatosis
Wilms' tumour
ADPKD
ARPKD
A favourite question is an Alport's patient with a failing renal transplant. This may
be caused by the presence of anti-GBM antibodies leading to a Goodpasture's
syndrome like picture
microscopic haematuria
progressive renal failure
bilateral sensorineural deafness
lenticonus: protrusion of the lens surface into the anterior chamber
retinitis pigmentosa
*in around 85% of cases - 10-15% of cases are inherited in an autosomal recessive
fashion with rare autosomal dominant variants existing
Amyloidosis: types
AL amyloid
AA amyloid
Cholesterol embolisation
Overview
Features
eosinophilia
purpura
renal failure
livedo reticularis
diabetic nephropathy
chronic glomerulonephritis
chronic pyelonephritis
hypertension
adult polycystic kidney disease
Serum creatinine may not provide an accurate estimate of renal function due to
differences in muscle. For this reason formulas were develop to help estimate the
glomerular filtration rate (estimated GFR or eGFR). The most commonly used
formula is the Modification of Diet in Renal Disease (MDRD) equation, which
uses the following variables:
serum creatinine
age
gender
ethnicity
The majority of patients with chronic kidney disease (CKD) will require more than
two drugs to treat hypertension. ACE inhibitors are first line and are particularly
helpful in proteinuric renal disease (e.g. diabetic nephropathy). As these drugs tend
to reduce filtration pressure a small fall in glomerular filtration pressure (GFR) and
rise in creatinine can be expected. NICE suggest that a decrease in eGFR of up to
25% or a rise in creatinine of up to 30% is acceptable, although any rise should
prompt careful monitoring and exclusion of other causes (e.g. NSAIDs). A rise
greater than this may indicate underlying renovascular disease.
*the NKF K/DOQI guidelines suggest a lower cut-off of less than 30 ml/min
Ciclosporin
nephrotoxicity
hepatotoxicity
fluid retention
hypertension
hyperkalaemia
hypertrichosis
hyperplasia of gum
tremor
impaired glucose tolerance
Indications
Stage 1
Stage 5
The timeline given here is for type 1 diabetics. Patients with type 2 diabetes
mellitus (T2DM) progress through similar stages but in a different timescale -
some T2DM patients may progress quickly to the later stages
Erythropoietin
Side-effects of erythropoietin
There are a number of reasons why patients may fail to respond to erythropoietin
therapy:
iron deficiency
inadequate dose
concurrent infection/inflammation
hyperparathyroid bone disease
aluminium toxicity
*the risk is greatly reduced with darbepoetin
Fanconi syndrome
Causes
Causes
idiopathic
secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy
HIV
heroin
Alport's syndrome
sickle-cell
Knowing a few key facts is the best way to approach the difficult subject of
glomerulonephritis:
Membranous glomerulonephritis
post-streptococcal glomerulonephritis
subacute bacterial endocarditis
systemic lupus erythematosus
mesangiocapillary glomerulonephritis
Goodpasture's syndrome
Features
pulmonary haemorrhage
followed by rapidly progressive glomerulonephritis
smoking
lower respiratory tract infection
pulmonary oedema
inhalation of hydrocarbons
young males
Investigations
renal biopsy: linear IgG deposits along basement membrane
raised transfer factor secondary to pulmonary haemorrhages
Management
plasma exchange
steroids
cyclophosphamide
massive proteinuria
normal or large kidneys
focal segmental glomerulosclerosis with focal or global capillary collapse on
renal biopsy
elevated urea and creatinine
normotension
Haematuria
The management of patients with haematuria is often difficult due to the absence
of widely followed guidelines. It is sometimes unclear whether patients are best
managed in primary care, by urologists or by nephrologists.
Management
Current evidence does not support screening for haematuria. The incidence of non-
visible haematuria is similar in patients taking aspirin/warfarin to the general
population hence these patients should also be investigated.
Testing
Causes
Investigations
Management
Henoch-Schonlein purpura
Features
palpable purpuric rash (with localized oedema) over buttocks and extensor
surfaces of arms and legs
abdominal pain
polyarthritis
features of IgA nephropathy may occur e.g. haematuria, renal failure
Treatment
Prognosis
Hyperkalaemia: management
Basics
Presentations
Associated conditions
alcoholic cirrhosis
coeliac disease/dermatitis herpetiformis
Management
Membranous glomerulonephritis
Causes
idiopathic
infections: hepatitis B, malaria
malignancy: lung cancer, lymphoma, leukaemia
drugs: gold, penicillamine, NSAIDs
systemic lupus erythematosus (class V disease)
Management
Mesangiocapillary glomerulonephritis
Overview
Type 1
Type 3
Management
Features
nephrotic syndrome
normotension - hypertension is rare
highly selective proteinuria*
renal biopsy: electron microscopy shows fusion of podocytes
Management
*only intermediate-sized proteins such as albumin and transferrin leak through the
glomerulus
Nephrotic syndrome
Triad of:
diabetes mellitus
systemic lupus erythematosus
amyloidosis
Drugs
Others
congenital
neoplasia: carcinoma, lymphoma, leukaemia, myeloma
infection: bacterial endocarditis, hepatitis B, malaria
Complications
SIGN issued guidance on the control of pain in adults with cancer in 2008.
Selected points
When increasing the dose of opioids the next dose should be increased by 30-50%.
From To
Oral codeine Oral morphine Divide by 10
Oral tramadol Oral morphine Divide by 5
From To
Oral morphine Oral oxycodone Divide by 2
The BNF states that oral morphine sulphate 80-90mg over 24 hours is
approximately equivalent to one '25 mcg/hour' fentanyl patch, therefore product
literature should be consulted.
From To
Oral morphine Subcutaneous diamorphine Divide by 3
Oral oxycodone Subcutaneous diamorphine Divide by 1.5
Papillary necrosis
Causes
chronic analgesia use
sickle cell disease
TB
acute pyelonephritis
diabetes mellitus
Features
Plasma exchange
Guillain-Barre syndrome
myasthenia gravis
Goodpasture's syndrome
ANCA positive vasculitis e.g. Wegener's, Churg-Strauss
TTP/HUS
cryoglobulinaemia
hyperviscosity syndrome e.g. secondary to myeloma
Renal cell cancer is also known as hypernephroma and accounts for 85% of
primary renal neoplasms. It arises from proximal renal tubular epithelium
Associations*
Features
Management
*incidence of renal cell cancer is only slightly increased in patients with autosomal
dominant polycystic kidney disease
The table below summarises the appearance of different types of renal stone on x-
ray
*stag-horn calculi involve the renal pelvis and extend into at least 2 calyces. They
develop in alkaline urine and are composed of struvite (ammonium magnesium
phosphate, triple phosphate). Ureaplasma urealyticum and Proteus infections
predispose to their formation
Calcium stones
Oxalate stones
allopurinol
urinary alkalinization e.g. oral bicarbonate
Risk factors
dehydration
hypercalciuria, hyperparathyroidism, hypercalcaemia
cystinuria
high dietary oxalate
renal tubular acidosis
medullary sponge kidney, polycystic kidney disease
beryllium or cadmium exposure
Risk factors for urate stones
gout
ileostomy: loss of bicarbonate and fluid results in acidic urine, causing the
precipitation of uric acid
Drug causes
The human leucocyte antigen (HLA) system is the name given to the major
histocompatibility complex (MHC) in humans. It is coded for on chromosome 6.
Graft survival
Post-op problems
ATN of graft
vascular thrombosis
urine leakage
UTI
Hyperacute acute rejection
All three types of renal tubular acidosis (RTA) are associated with hyperchloraemic
metabolic acidosis (normal anion gap)
causes hyperkalaemia
causes include hypoaldosteronism, diabetes
Investigation
Retroperitoneal fibrosis
Associations
Riedel's thyroiditis
previous radiotherapy
sarcoidosis
inflammatory abdominal aortic aneurysm
drugs: methysergide
Rhabdomyolysis
Rhabdomyolysis will typically feature in the exam as a patient who has had a fall
or prolonged epileptic seizure and is found to have acute renal failure on admission
Features
Causes
seizure
collapse/coma (e.g. elderly patients collapses at home, found 8 hours later)
ecstasy
crush injury
McArdle's syndrome
drugs: statins
Management
WHO classification
treat hypertension
corticosteroids if clinical evidence of disease
immunosuppressants e.g. azathiopine/cyclophosphamide
Sterile pyuria
Causes
Features
Tuberous sclerosis
Cutaneous features
Neurological features
developmental delay
epilepsy (infantile spasms or partial)
intellectual impairment
Also
Features
Investigations
Management
steroids
cyclophosphamide (90% response)
plasma exchange
median survival = 8-9 years
Wilms' tumour
Features
Associations
Beckwith-Wiedemann syndrome
as part of WAGR syndrome with Aniridia, Genitourinary malformations,
mental Retardation
hemihypertrophy
around one-third of cases are associated with a mutation in the WT1 gene on
chromosome 11
Management
nephrectomy
chemotherapy
radiotherapy if advanced disease
prognosis: good, 80% cure rate