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Nephrology 10.4.25 Dr Sophia Hwai and Dr Aeron RaphaelLearningOutcomes To revise the main presentations within Nephrology including: ● Acute kidney injury (AKI): Diagnosis, classification, and management ● Chronic kidney disease (CKD): Staging, management, and complications ● Nephrotic syndrome: Presentation, causes, and management ● Urinary tract infections: Diagnosis, treatment, and prevention ● Electrolyte disturbances: Hyperkalaemia, hyponatremia, etc. ● Dialysis: Indications, types, complicationsLearningOutcomesQuestion 1 A 58-year-old male is on the surgical ward after undergoing a total nephrectomy two days previously. He appears well and examination findings are normal, although his urine output has dropped. His fluid chart shows he has passed 850ml of urine in the past 24 hours. He weighs 80kg. Blood tests show a creatinine rise to 108 µmol/L from a baseline of 90 µmol/L (normal range 60 - 120 µmol/L). What is the most likely diagnosis? A. Normal physiological response after surgery B. Post nephrectomy oliguria C. Benign prostatic hypertrophy D. AKI stage 1 E. SIADHQuestion 1 A 58-year-old male is on the surgical ward after undergoing a total nephrectomy two days previously. He appears well and examination findings are normal, although his urine output has dropped. His fluid chart shows he has passed 850ml of urine in the past 24 hours. He weighs 80kg. Blood tests show a creatinine rise to 108 µmol/L from a baseline of 90 µmol/L (normal range 60 - 120 µmol/L). What is the most likely diagnosis? A. Normal physiological response after surgery B. Post nephrectomy oliguria C. Benign prostatic hypertrophy D. AKI stage 1 E. SIADHQuestion 1-Explanation This gentleman has an AKI stage 1 as per the KDIGO criteria. His weight is 80kg as so the minimum amount of urine we would expect in 24 hours is 0.5ml/kg/hr x 80kg x 24hr = 960ml. His AKI is likely due to dehydration.Acute KidneyInjury AKI is the sudden deterioration of kidney function, categorised into pre-renal, renal, and post-renal causes. KDIGO criteria for AKI stage 1: - Increase in serum creatinine of >26.5 𝝻mol/L within 48hrs OR - Increase in serum creatinine of 1.5x baseline within 7days OR - Urine output <0.5 ml/kg/hr for >6hrs Stage 2: - Increase in serum creatinine of up to 3x baseline within 7days - Urine output <0.5 ml/kg/hr for >12hrs Stage 3: - Increase in serum creatinine of >354 𝝻mol/L - Increase in serum creatinine of >3x baseline within 7days - Urine output <0.3 ml/kd/hr for >24hrs - Anuria for 12hrs Clinical presentation: depends on the cause of AKI Acute KidneyInjury Investigations: - Bloods (FBC, U&Es, LFTs, CRP, bone profile) - Bedside tests (urinalysis, urine culture, ABG/VBG, Obs, ECG) - Imaging (bladder scan, renal ultrasound, fundoscopy, CT KUB) - Special tests (renal screen, biopsy) Management: t p 1. Correct hypovolaemia - give regular small 250ml fluid boluses of u crystalloid, daily U&Es, fluid input/output S 2. Correct hyperkalaemia - 10ml 10% calcium chloride/ gluconate, insulin/dextrose, saline nebs 3. Review medications: w a. Stop nephrotoxics (DAMN - Diuretics, ACEi, Metformin, NSAIDs) v b. Discuss Toxicity Bear with parent team R c. Review all drug doses in renal impairment 4. Review bladder scan (>500ml residual -> catheterise) and other imaging 5. Alert senior early t 6. Refer to nephrology if: a - ?Intrinsic renal disease Source: GrepMed s - Renal transplant E - BG CKD 4-5 - Dialysis indicatedAcute KidneyInjury Hydronephrosed Kidney TCC in bladder Source: POCUS journal Source: RadiopaediaQuestion 2 A 72-year-old Caucasian man presents to his GP with bilateral lower limb swelling. He has type 2 diabetes which he manages with metformin. On examination, he has pitting peripheral oedema, a clear chest and normal heart sounds. He has a normal full blood count and B-type natriuretic peptide (BNP) but elevated triglycerides, hypoalbuminaemia and serum creatinine of 167 umol/L. His protein-creatinine ratio is 490 mg/mmol (< 50 mg/mmol). Urinalysis showed no blood and protein +++ What is the most likely underlying diagnosis? A. Heart failure B. Minimal change disease C. IgA nephropathy D. Membranous nephropathy E. Diabetic nephropathy.Question 2 A 72-year-old Caucasian man presents to his GP with bilateral lower limb swelling. He has type 2 diabetes which he manages with metformin. On examination, he has pitting peripheral oedema, a clear chest and normal heart sounds. He has a normal full blood count and B-type natriuretic peptide (BNP) but elevated triglycerides, hypoalbuminaemia and serum creatinine of 167 umol/L. His protein-creatinine ratio is 490 mg/mmol (< 50 mg/mmol). Urinalysis showed no blood and protein +++ What is the most likely underlying diagnosis? A. Heart failure B. Minimal change disease C. IgA nephropathy D. Membranous nephropathy E. Diabetic nephropathy.Question 2-Explanation This gentleman matches the criteria for nephrotic syndrome and his age points towards membranous nephropathy which is the most common cause of nephrotic syndrome in adults.Nephroticsyndrome Investigations: Nephrotic syndrome is diagnosed with the presence of: - Bloods (FBC, U&Es, LFTs, CRP, bone profile) - Proteinuria > 3.5 grams/24 hours - Bedside tests (urinalysis, urine culture, ABG/VBG, Obs, - Serum albumin < 30 grams/litre ECG, protein:creatinine ratio) - Peripheral oedema - Imaging (bladder scan, renal ultrasound, fundoscopy, CT KUB, CXR, CT chest) Clinical features: - Special tests (renal screen, biopsy) - Anti-GBM, ANA, dsDNA, ANCA, cryoglobulins - Frothy urine due to protein - Myeloma screen: serum electrophoresis, - Swelling over the face and body serum free light chains, immunoglobulins - Weight gain due to fluid retention - Viral screen: HepB, HepC, HIV, CMV, EBV - Fatigue Differentials investigations: - Lethargy - Hypoalbuminaemia: Muehkrcke’s lines - white - Heart failure - NTproBNP - CV risk factors - HbA1c, fasting glucose, lipid profile transverse lines on the nails - Hyperlipidaemia: xanthelasma, xanthoma Complications investigations: - Hypercoagulability - coag screen, doppler US, CTPA - Vit D deficiency - bone profileNephroticsyndrome 1. Restrict fluid intake <1.5L/day 2. Restrict salt intake <2g/day 3. Dietary input Management: 4. Daily weights - target 1-2kg weight loss/day 5. TEDs 1. Deal with the acute problem 2. Combat the cause 3. Optimise renoprotection Mainstay of treatment for most nephrotic syndromes is steroids with planned weaning after remission. 6. Steroids 7. Immunosuppressants Renoprotective treatment is similar for CKD. 8. ACEi/ARBs 9. Vaccinations 10. Consider statinsQuestion 3 A 26-year-old man presents to A&E with shortness of breath and haemoptysis. He has been feeling generally unwell for three days and started coughing up blood this morning. He smokes 10 cigarettes a day but otherwise has no past medical history. His creatinine is 200 umol/L (baseline 90), and urinalysis shows protein ++ and blood +++. An intrinsic cause of AKI is suspected and a renal biopsy is performed. What would be expected on renal biopsy? A. Subendothelial and mesangium immune deposits of electron-dense material forming a ‘tram-track’ appearance B. Effacement of foot processes and fusion of podocyte on electron microscopy C. Formation of epithelial crescent in glomeruli D. ‘Starry sky’ appearance on immunofluorescence E. Mesangial IgA immune complex depositionQuestion 3 A 26-year-old man presents to A&E with shortness of breath and haemoptysis. He has been feeling generally unwell for three days and started coughing up blood this morning. He smokes 10 cigarettes a day but otherwise has no past medical history. His creatinine is 200 umol/L (baseline 90), and urinalysis shows protein ++ and blood +++. An intrinsic cause of AKI is suspected and a renal biopsy is performed. What would be expected on renal biopsy? A. Subendothelial and mesangium immune deposits of electron-dense material forming a ‘tram-track’ appearance B. Effacement of foot processes and fusion of podocyte on electron microscopy C. Formation of epithelial crescent in glomeruli D. ‘Starry sky’ appearance on immunofluorescence E. Mesangial IgA immune complex depositionQuestion 3-Explanation AKI + pulmonary haemorrhage that progresses rapidly suggests anti-GBM disease aka. Goodpasture disease.Anti-GBM disease Anti-glomerular basement membrane disease is characterised by anti-GBM IgG antibodies attacking type IV collagen antigens in the kidney and lungs (type II hypersensitivity reaction). It relatively rare compared to other types of glomerulonephritis. Clinical features: - Haematuria + Haemoptysis - Respiratory symptoms: chest pain, dyspnoea - Systemic symptoms: fatigue, weight loss Investigations: - Bloods (FBC, U&Es, LFTs, CRP, bone profile) - Bedside tests (urinalysis, urine culture, ABG/VBG, Obs, ECG, protein:creatinine ratio) - Imaging (bladder scan, renal ultrasound, fundoscopy, CT KUB, CXR, CT chest) - Special tests (renal screen, biopsy) - Anti-GBM, ANA, dsDNA, ANCA, cryoglobulins - Myeloma screen: serum electrophoresis, serum free light chains, immunoglobulins - Viral screen: HepB, HepC, HIV, CMV, EBVAnti-GBM disease Management: 1. Supportive 2. Suppress autoantibodies -> High-dose steroids + cyclophosphamide 3. Remove autoantibodies -> Plasma exchange ~2 weeks 4. +/- dialysis 5. +/- renal transplant If significant pulmonary haemorrhage -> bronchoscopy +/- angiography with embolisation ^ Pulmonary complications are the most common cause of death due to anti-GBMGlomerular diseases Source: EdrenNephroticsyndromes Minimal Change FSGS (Focal segmental Membranous Diabetic Amyloidosis SLE glomerulosclerosis) nephropathy Definition Most common cause May be primary to Most common cause of Affects patients with Chronic inflammation due Renal involvement in of nephrotic syndrome secondary to HIV or nephrotic syndrome in T1DM or T2DM as a to AL amyloid light chain SLE in children heroin. older patients. worsening progression of deposition in the kidneys microalbuminuria Renal Foot podocyte Segmental sclerosis Immune complex Thickening of the Amyloid stains congo red Glomerular biopsy effacement. Glomeruli deposition on basement glomerular basement and shows apple green (subepithelial) findings looks normal under membrane -> membrane, mesangial birefringence under capillary inflammation light microscopy. thickening without expansion and polarised light due to immune hypercellularity or Kimmelstiel-Wilson complex deposition proliferation. ‘Spike and nodules. dome’ appearance Clues Swollen child. Associated with Associated with History of diabetes and no Systemic features Systemic features Responds to steroids. hyperlipidaemia and hyperlipidaemia and other risk factors for other peripheral oedema peripheral oedema types of GNNephriticsyndromes Post-streptococcal MPGN / MCGN IgA nephropathy ANCA-associated Anti-GBM/ Goodpastures/ (Membranoproliferative) vasculitis (GPA, EGPA, RPGN (rapidly MPA) progressive glomerulonephritis) Definition A mixture of inflammation A type of rapidly IgA deposition in the Multiple types of Rare; Anti-GBM antibodies and neutrophil infiltration progressive mesangium. It’s the most autoimmune small vessel to non-collagenous domain caused by group A glomerulonephritis. Can be common type of vasculitides due to ANCA of type IV collagen B-haemolytic streptococci caused by Hep C, mixed glomerulonephritis antibody cryoglobulinemia, worldwide. monoclonal gammopathies Renal biopsy Diffuse IgG and C3 ‘Double contour’ or ‘tram Diffuse mesangial IgA Focal and segmental Focal and segmental findings immune-complex track’ crescents on immune complex deposition necrotising necrotising crescents and deposition. Subepithelial basement membrane and cell proliferation glomerulonephritis linear IgG along the ‘humps’ and ‘starry sky’ basement membrane appearance on electron microscopy. Clues Haematuria 1-3 weeks after AKI/ sharp rise in creatinine Haematuria 1-3 days after Positive p-ANCA or AKI/ sharp rise in creatinine infection in children - may infection in young adults c-ANCA. + Rapidly progressive be otherwise asymptomatic. haemoptysis and pulmonary haemorrhageQuestion 4 A 49-year-old man with multiple comorbidities presents with dark-coloured urine and ache-like pain in his forearms and thighs. His U&Es show elevated urea and a creatinine of 210 umol/L (baseline 90 umol/L). His CK level is 2000 u/L (35-250 u/L). He recalls starting a new medication 2 weeks ago. Which of the following medications is the most likely precipitator? A. B-blocker B. ACE inhibitor C. Gentamicin D. Statin E. Loop diureticQuestion 4 A 49-year-old man with multiple comorbidities presents with dark-coloured urine and ache-like pain in his forearms and thighs. His U&Es show elevated urea and a creatinine of 210 umol/L (baseline 90 umol/L). His CK level is 2000 u/L (35-250 u/L). He recalls starting a new medication 2 weeks ago. Which of the following medications is the most likely precipitator? A. B-blocker B. ACE inhibitor C. Gentamicin D. Statin E. Loop diureticQuestion 4-Explanation This gentleman is most likely to be experiencing rhabdomyolysis. Statins are well-known for causing rhabdomyolysis.Rhabdomyolysis Rhabdomyolysis is the breakdown of skeletal muscle, releasing myoglobin and electrolytes into the blood. It can result after trauma, a long lie, status epilepticus, compartment syndrome, or after medication use. Clinical features: - Dark coloured urine + AKI - Muscle pain (may be disproportionate to injury) Investigations: - Bloods (FBC, U&Es, LFTs, CRP, bone profile, Creatinine Kinase) - Bedside tests (urinalysis, ABG/VBG, Obs, ECG) - Imaging (N/A) - Special tests (muscle biopsy at least 1 month after acute episode) Management: - SupportiveQuestion 5 A 30-year-old woman with end-stage renal disease presents to A&E at night. For the past 2 months she has used Continuous Ambulatory Peritoneal Dialysis (CAPD). Today, she feels unwell with abdominal pain and describes her last bag as being 'cloudy'. What is the most appropriate management? A. Dip urine and prescribe PO steroids B. Refer to renal C. Give IV vancomycin and ceftazidime D. Reduce ultrafiltration rate E. Replace the peritoneal catheter and give PO metronidazoleQuestion 5 A 30-year-old woman with end-stage renal disease presents to A&E at night. For the past 2 months she has used Continuous Ambulatory Peritoneal Dialysis (CAPD). Today, she feels unwell with abdominal pain and describes her last bag as being 'cloudy'. What is your next step in management? A. Dip urine and prescribe PO steroids B. Refer to renal C. Give IV vancomycin D. Reduce ultrafiltration rate E. Replace the peritoneal catheter and give PO metronidazoleQuestion 5-Explanation This lady most likely has an infection related to peritoneal dialysis which requires urgent treatment. This would require vancomycin and ceftazidime added to dialysis fluid, not IV. Referral to renal would be appropriate as they would be able to organise this and sample her peritoneal fluid as the same time.Dialysis There are two main types of dialysis: haemodialysis and peritoneal dialysis. Haemodialysis Peritoneal dialysis - Requires AV fistula - A peritoneal catheter runs dialysate fluid through the - Solutes are drawn across the membrane in the dialysis abdominal cavity and is left for a few hours before being machine down a diffusion gradient to normalise drained. electrolytes and remove urea - There are two types: -> CAPD 3-4x/day, or -> APD overnight Complications: Complications: - Hypotension - Bacterial peritonitis (Staph. Epidermidis most common) - Muscle cramps (electrolyte disturbances) - Sclerosing encapsulating peritonitis - Arrhythmias - Small bowel obstruction - Dialysis disequilibrium syndrome (rare) - Catheter leaks - AV fistula ishcaemic steal syndromeDialysis Acute indications for dialysis: Other indications: - eGFR 5-7 ml/min/1.73m2 A Acidosis (pH <7.2 OR bicarb <10mmol/L) - While awaiting renal transplant E Electrolytes (persistent raised K+ >7mmol/L) I Intoxication (BLAST - Barbituates, Lithium, Alcohol, Salicylates, Theophylline) O Oedema (refractory pulmonary oedema) U Uraemia (urea >40 OR uraemic endocarditis OR uraemic encephalitis)LearningOutcomesQuestion 6 A 74F presents to the acute medical unit with fevers, loose stools and abdominal pain. On her past medical history you note, CKD4 treated with a renal transplant 18 months ago, T2DM, and HTN. Her bloods show a reduced WCC, Hb and Neutrophils, with a raised CRP. What is the most likely cause of her presentation? a) HIV infection b) CMV infection c) Toxoplasmosis d) B. cereus e) E. coliQuestion 6 A 74F presents to the acute medical unit with fevers, loose stools and abdominal pain. On her past medical history you note, CKD4 treated with a renal transplant 18 months ago, T2DM, and HTN. Her bloods show a reduced Hb and Neutrophils, with a raised CRP and WCC. What is the most likely cause of her presentation? a) HIV infection b) CMV infection c) Toxoplasmosis d) B. cereus e) E. coliRenal transplants The definitive form of renal replacement therapy for patients with end stage renal disease. Will often need chronic long term follow up, as well as immunosuppression Most commonly prescribed - Tacrolimus; Mycophenolic acid. Impairs innate immune response to both host reaction and to pathogens. CMV is the most opportunistic infection in immunosuppressed transplant patients.Question 7 A 34M presents to A&E with new-onset frank haematuria, pain in his groin radiating up to his left back. On examination he is found to have a flank mass, and on exposure of his scrotum you find a left sided mass that transilluminates and becomes more prominent on standing. What is the anatomical relation for this examination finding? a) Ureteric backflow into the urethra b) Spermatic cord blockage c) Left testicular vein drainage into the left renal vein d) Chronic venous insufficiency e) Lymphatic drainage to the testiclesQuestion 7 A 34M presents to A&E with new-onset frank haematuria, pain in his groin radiating up to his left back. On examination he is found to have a flank mass, and on exposure of his scrotum you find a left sided mass that transilluminates and becomes more prominent on standing. What is the anatomical relation for this examination finding? a) Ureteric backflow into the urethra b) Spermatic cord blockage c) Left testicular vein drainage into the left renal vein d) Chronic venous insufficiency e) Lymphatic drainage to the testiclesRenalCellCancer May be caused by a renal cell tumour that compresses the left renal vein, causing backflow into the left testicular vein >> blood backs up into the pampiniform plexusRenalCellCancer May be caused by a renal cell tumour that compresses the left renal vein, causing backflow into the left testicular vein >> blood backs up into the pampiniform plexusRenalCellCancer May be caused by a renal cell tumour that compresses the left renal vein, causing backflow into the left testicular vein >> blood backs up into the pampiniform plexus While not all varicoceles indicate cancer, may have a compressive mass or vascular spread of malignancyQuestion 8 Sodium 135 13 A 65M presents to his GP his annual 5–146 well-man check up. As part of this the GP mmol/L reviews his U&Es: Potassium 4.0 3.5 –5.3 mmol/L What monitoring should be commenced by the GP on discharge? Urea 8.0 2.5 – 7.8 mmol/L a) Hba1c b) Sodium, Potassium and Calcium eGFR 20 >90ml/min/1 .73m2 c) Calcium, Phosphate, PTH levels d) Haemoglobin, White cell counts, Creatinine 150 Men μmol/L Neutrophil count Women e) Blood pressure, heart rate and 45–84 μmol/ saturations LQuestion 8 Sodium 135 13 A 65M presents to his GP his annual 5–146 well-man check up. As part of this the GP mmol/L reviews his U&Es: Potassium 4.0 3.5 –5.3 mmol/L What monitoring should be commenced by the GP on discharge? Urea 8.0 2.5 – 7.8 mmol/L a) Hba1c b) Sodium, Potassium and Calcium eGFR 20 >90ml/min/1 .73m2 c) Calcium, Phosphate, PTH levels d) Haemoglobin, White cell counts, Creatinine 150 Men μmol/L Neutrophil count Women e) Blood pressure, heart rate and 45–84 μmol/ saturations LCKDNICEGuidelines NICE Guidelines 203 - Chronic kidney disease: assessment and managementQuestion 9 A 10F presents to Paeds ED with acute bloody diarrhoea following eating at a picnic. She is admitted and is commenced on steroids and supportive fluid therapy. Despite this she develops an acute kidney injury, with a prolonged bleeding time on a coagulation screen. You take a blood sample and examine it on a light microscope. What findings would you be most likely to see on blood film microscopy? a) Red blood cell schistocytes b) ‘Rough’ looking red blood cells c) Polymorphic white blood cells d) Large red blood cells e) MacrophagesQuestion 9 A 10F presents to Paeds ED with acute bloody diarrhoea following eating at a picnic. She is admitted and is commenced on steroids and supportive fluid therapy. Despite this she develops an acute kidney injury, with a prolonged bleeding time on a coagulation screen. You take a blood sample and examine it on a light microscope. What findings would you be most likely to see on blood film microscopy? a) Red blood cell schistocytes b) ‘Rough’ looking red blood cells c) Polymorphic white blood cells d) Large red blood cells e) MacrophagesHaemolytic-Uraemicsyndrome A syndrome characterised by anaemia secondary to haemolysis, new AKI with Uraemia, and thrombycytopaenia. The majority of cases occur secondary to infection with a Shiga toxin producing Escherichia coli. Blood film is key for diagnosis - will show schistocytes (‘burst’) red blood cells. Bursting -> loss of RBCs -> loss of haemoglobin causing anaemia. Thrombocytopaenia caused by endothelial damage causing microclots using up platelets (primary haemostasis)Question 10 A 60M with end stage renal failure and peripheral vascular disease presents to the vascular ward awaiting definitive management of a non-healing chronic venous ulcer. During this admission he develops a new bradycardia and oliguria. A VBG is taken which shows: Sodium 135; Potassium 6.3; Urea 8.0; GFR 15; Creatinine 300; Hb 90; WCC 4.5; Neuts 5.0. An ECG is taken which shows: What is the best initial management a) Salbutamol 5mg Neb b) Lokelma 10g TDS c) Calcium gluconate 10% 30ml STAT d) Glucose-K+ infusion e) Hartmann’s 1L fluid resuscitationQuestion 10 A 60M with end stage renal failure and peripheral vascular disease presents to the vascular ward awaiting definitive management of a non-healing chronic venous ulcer. During this admission he develops a new bradycardia and oliguria. A VBG is taken which shows: Sodium 135; Potassium 6.3; Urea 8.0; GFR 15; Creatinine 300; Hb 90; WCC 4.5; Neuts 5.0. An ECG is taken which shows: What is the best initial management a) Salbutamol 5mg Neb b) Lokelma 10g TDS c) Calcium gluconate 10% 30ml STAT d) Glucose-K+ infusion e) Hartmann’s 1L fluid resuscitationHyperkalaemia Common electrolyte abnormality seen on surgical wards Aetiology varied: concurrent chronic illness, acute stressor such as infection Key points: ● Identify ECG changes if present ● Acute and Long term K+ management SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! Sign up to our next session on MedAll Take part in our research survey See all our upcoming events www.medticteaching.com | Email: medticteaching@gmail.com | Youtube @medtic | Instagram @medtic.teaching | Tiktok @medticteaching