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Medical Series: Nephrology 2 Dr. Inuri Patabendi Post-Foundation Doctor F3 SSocial Medias SNephrology Part 2 By Inuri Patabendi F3 S Contents SCKD SRenal replacement therapy SIntrinsic renal disease True or false CKD is the reduction of kidney function and/or structural damage for 3 weeks or more False CKD is the reduction of kidney function and/or structural damage for 3 weeks or more CKD is the reduction of kidney function and/or structural damage for 3 months or morehttps://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf Chronic kidney disease S Two blood tests 90 days apart Stage Description egfr 1 Normal +kidney damage >90 2 Mild reduction +kidney damage 60-89 3a Mild-moderate reduction 45-59 3b Moderate to severe reduction 30-44 4 Severe reduction 15-29 5 Kidney failure <15 Adapted with the kind permission of the Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group, 2013. Kidney damage features S Proteinuria: urinary albumin: creatinine ratio [ACR] S Abnormalities detected by histology S Structural abnormalities detected by imaging S History of kidney transplantation Albumin creatinine ratio Stage ACR (mg/g) Description A1 <3 Mild increase A2 3-300 Moderate increase A3 >300 Severe increase Threshold of 70 True or false? The most common causes of chronic kidney disease are… Hypertension and diabetes True The most common causes of chronic kidney disease are… Hypertension and diabetes Hypertension and CKD Hypertensive nephrosclerosis S 80% of CKD patients S Common cause of CKD S Vascular diseasgl, moeruloscerosis, interstitial fibrosis and tubular atrophy S Retinopathy, left ventricular hypertrophy S First line- ACE inhibitors or ARBs https://www.niddk.nih.gov/media-assets/9555/B2-Image03%20- %20Kidney+Nephron_FINAL.jpg?imbypass=truehttps://www.cdc.gov/kidneydisease/images/take-care- problems.png29 year old lady recently started on ramipril for HTN. Blood tests show a rise in creatine 120 to 180 in 1 weeks. What is the most likely diagnosis? A. Fibromuscular dysplasia B. Renal artery stenosis due to atherosclerosis C. CKD secondary to HTN D. Expected rise when starting ramipril29 year old lady recently started on ramipril for HTN. Blood tests show a rise in creatine 120 to 180 in 1 weeks. What is the most likely diagnosis A. Fibromuscular dysplasia B. Renal artery stenosis due to atherosclerosis C. CKD secondary to HTN D. Expected rise when starting ramipril Fibromuscular dysplasia S Disorder of proliferation of cells within artery wall S Renal and internal carotid artery S More common in young female S Headache, HTN, bruits S AKI after ACE inhibitor S eGFR change is 25% or more, or the change in serum creatinine is 30% or more S MR angiography: string of beads appearance of renal arteries S Renal artery stenosis is due to atherosclerosis more commonly S Reversible if severe can lead to CKD https://prod-images-static.radiopaedia.org/images/8401315/1a1c776c44451e9c2e38be119ca60e_gallery.jpg Diabetes and CKD Diabetic nephropathy S Decreased kidney function with proteinuria S Can cause nephrotic syndrome if severe S Hyperglycaemia- increased production of metabolic products causing inflammation and fibrosis, filtration rate is also affected S Correlation with diabetic retinopathy S Ace inhibitors/ARBs and glycaemic control Causes of CKD S Hypertension S Diabetes mellitus S Autosomal dominant polycystic kidney disease (, lport’s syndrome S Glomerular disease S Nephrotoxics S Infections S Systemic disease: SLE, vasculitis myelomahttps://www.cdc.gov/kidneydisease/images/take-care- problems.png Which of these is least associated with ADPKD? A. Liver cysts B. Berry aneurysms C. Mitral valve prolapse D. Sensorineural hearing loss E. Diverticulosis Which of these are least associated with ADPKD? A. Liver cysts B. Berry aneurysms Alport’s C. Mitral valve prolapse syndrome D. Sensorineural hearing loss E. DiverticulosisAD polycystic kidney disease S ADPKD 1 earlier renal failure, ADPKD-2 S 1 in 1000 Screen with USS S Features S Hypertension CT or MRI S Hematuria S Renal failure S Flank pain S Cyst hemorrhage S Renal stones S Urinary tract infections S Liver, pancreatic, spleen andepididymal cysts S Berry aneurysms S Mitral valve prolapse S Diverticulosishttps://www.cdc.gov/kidneydisease/images/take-care- problems.png True or false ADPKD causes an irreversible decline in kidney function with no treatments available to slow the progression False ADPKD causes an irreversible decline in kidney function with treatments available to slow the progression ADPKD management S Control BP: Ace inhibitors S Increase water intake, decrease salt intake S Tolvapta: S selective vasopressin 2 antagonist S slows growth of cysts S for CKD 2 or 3 at start S or rapidly progressive kidney function S Dialysis S Transplant S Nephrectomy True or false? Chronic kidney disease should be managed by a local renal team . False Chronic kidney disease should be managed by a local renal team . Management of CKD S Primary care S Assess and modify risk factors : diabetes, HTN, CVD S Healthy lifestyle S Avoid NSAIDs S Ensuring the person is offered immunizations for influenza and pneumococcal disease. True or false People with CKD are–10 times more likely to die prematurely from CVD than they are to progress to end-stage renal disease. True People with CKD are–10 times more likely to die prematurely from CVD than they are to progress to end-stage renal disease. • Chronic inflammation- vascular and myocardial remodeling • Vascular calcification, atherosclerosis Monitoring S EGFR S Urine ACR S Full blood count (renal anaemia) S Serum calcium (low) S Phosphate (high) S Vitamin D (low) S Parathyroid hormone (renal bone disorder) When to refer S An eGFR <30 S Accelerated progression of CKD S diabetes mellitus70 mg/mmol or more, unless known to be associated with S A urinary ACR of 30 mg/mmol or more together with persistent haematuria, after exclusion of a urinary tract infection (UTI) S Uncontrolled hypertension S A rare or genetic cause of CKD S Suspected renal artery stenosis S A suspected complication of CKD RenalAnaemia S Reduced EPO–normochromic normocytic, egfr <30 S Anaemia also due to S diet S toxic effects of uraemia on bone marrow EPO stimulates RBC production in response to S reduced iron absorption S reduced red cell survival in HD hypoxia S poor platelet function so blood loss e.g. stress ulcer S blood tests S TargetHb 10-12 g/dL S Ensure iron levels are adequate S S/C erythropoeitin, darbopoeitin S Contraindnicatied in malignancy and strokehttps://www.cdc.gov/kidneydisease/images/take-care- problems.png89 year old of CKD comes to clinic for a revie. He has a list of ailments that he would like you to explain. Which of these symptoms would be least atributed to high urea levels? S Lost of appetite S Feels sick S Tingling and numbness in his feet S Poor concentration S Bone pain89 year old of CKD comes to clinic for a revie. He has a list of ailments that he would like you to explain. Which of these symptoms would be least atributed to high urea levels? S Lost of appetite S Feels sick S Tingling and numbness in his feet S Poor concentration S Bone pain Symptoms of ureamia S Anorexia S Nausea and vomiting S Itching- excoriations S Pericarditis S Peripheral neuropathy S Central nervous system abnormalities- poor concentration to coma When to consider dialysis in CKD S Impact of uraemia on life S biochemical measures S uncontrolled fluid overload S egfr 5-7 S Consider mode of dialysis S Support, understanding: how it will affect life Haemodialysis • 3 times a week, 4 hourly sessions Peritoneal dialysis • Access: AV fistula 6-8 weeks to • home based mature • risk of infections https://www.kdf.org.sg/haemodialysis https://rrtjournal.biomedcentral.com /articles/10.1186/s41100- 020-00307-7What is the treatment of choice for ESRF? A. Haemodilaysis B. Peritoneal dialysis C. Renal transplant D. Conservative managementWhat is the treatment of choice for ESRF? A. Haemodilaysis B. Peritoneal dialysis C. Renal transplant D. Conservative management Renal transplant S Live or disease donor S Reduced mortality than dialysis S Long term immunosupression S Risk of infection S Risk of malignancy S Non adherence –paedeatric to adult careBREAK Intrinsic renal disease S Acute tubular necrosis (ATN) S Glomerularnephritis S Vasculitis S Interstitial nephritis76 year old man, admitted with sepsis seondary to pneumonia. Has had 4 days IV antibiotics and IV fluids and fevers settled but his BP reamins at 90/60 and his renal function is deteriorating. What is the likely cause of his AKI? A. Pre-renal AKI B. Nephrotoxic ATN C. Ischaemic ATN D. Acute interstitial nephritis E. Acute glomerulonephrits76 year old man, admitted with sepsis seondary to pneumonia 4 days IV antibiotics and IV fluids, fevers settled but his HP reamins at 90/60 and his renal function is deteriorating. A. What is the likely cause of his AKI? B. Pre-renal AKI C. Nephrotoxic ATN D. Ischaemic ATN E. Acute interstitial nephritis F. Acute glomerulonephrits Acute tubular necrosis S Most common renal AKI S Tubular epithelium necrosis, necrotic cells bock lumen S Due to S Ischeamia (shock/sepsis) S Neperhotoxics S E.g. vancomyci, contrast, lead S Phases –oliguric, polyuric, recovery ANCA vasculitidies S Anti-neutrophil cytoplasmic antibody S Small-medium vessel vasculitis S Respiratory involvement upper or lower S Haematuria, proteinuria and renal failure S Systemic upset: fatigue, weight loss and fever S Immunosupressive therapy: steroids, cyclophosphamide44 year old man, fit and well, presents with AKI. Recently diagnosed with asthma for which he has been stared on monteluekast. He has a positive ANCA result. What is the most likely diagnosis? A. Granulomatosis with polyangitis B. Eosinophillic granulomatosis with polyangitis C. Anti-GBM disease D. Interstitial nephritis44 year old man, fit and well, presents with AKI. Recently diagnosed with asthma for which he has been stared on monteluekast. He has a positive ANCA result. What is the most likely diagnosis? A. Granulomatosis with polyangitis B. Eosinophillic granulomatosis with polyangitis C. Anti-GBM disease D. Interstitial nephritis Eososinophilic granulomatosis with polyangitis Churg Strauss syndrome S Small-medium vessel vasculitis S pANCA (perinuclear) –MPO antibody S Asthma, eosinophillia S Subucutaneus nodules S Mononeuritis multiplex S Can be precipitated by monteleukast (leukotrien receptor antagonist) Granulomatosis with polyangitis Wegner’sranulomatosis S Small vessel vasculitis S cANCA (cytoplasmic) -PR3 antibody S Epistaxis, sinusitis, haemoptysis, dyspnoea, saddle shaped nose S Rapidly progressive glomerulonephritis S Biopsy: epithelial crescents in Bowman’s capsuleAnti-glomerular basement membrane disease (Goodpastures’s syndrome) S Small vessel vasculitis S Anti-GBM antibodies against collagen type IV S Glomerular basement membrane S Alveolar basement membrane S Pulmonary haemorrhage S Rapidly progressive glomerulonephritis S Biopsy: linear IgG deposits along GBMhttps://www.cdc.gov/kidneydisease/images/take-care- problems.pngWhat is the first line management for a patient with confirmed anti-GBM disease? A. No treatment available B. Prednisolone C. Renal transplant D. Plasma exchange E. Ace-inhibitorsWhat is the first line management for a patient with confirmed anti-GBM disease? A. No treatment available B. Prednisolone Mx- • Plasma exchange C. Renal transplant • Steroids-IV methyprednisolone • Cyclophosphamide D. Plasma exchange E. Ace-inhibitors 68 year old gentleman admitted with AKI. He was recently started on a new medication by his GP but does not recall the name or what it was for. His bloods show an AKI stage 3 with raisedeosinophils. Urine dip shows Protein + WCC ++ + You suspect a diagnosis of acute interstitial nephritis. Which drug is least likely to be the culprit? S Flucloxacillin S Prednisolone S Ciprofloxacin S Allopurinol S Omeprazole 68 year old gentleman admitted with AKI. He was recently started on a new medication by his GP but does not recall the name or what it was for. His bloods show an AKI stage 3 with raised eosinophils. Urine dip shows Protein + WCC ++ + You suspect a diagnosis of acute interstitial nephritis. Which drug is least likely to be the culprit? S Flucloxacillin S Prednisolone S Ciprofloxacin S Allopurinol S Omeprazole Acute interstitial nephritis S Common drugs: S Penicillin, cephalosporins, rifampicin, NSAIDS, trimethoprim Stop the offending drug S Autoimmune: SLE,sarcoidosis, Sjogrens syndrone Prednisolone 1mg/kg S Infections S Fever, rash, arthralgia S AKI (eosinophilia) S Renal biopsy: marked interstitialedema and infiltrate in connective tissue S Urinalysis: sterile pyuria Nephritic screen S ANCA–vasculitis S Anti-GBM – Good Pasture’s syndrome S ANA- SLE S Myeloma: free serum light chains, bence jones protein, immunoglobulins (also for IgA nephropathy) S Complement- membranoproliferative GN S HIV , HepatitisTHANK YOU FOR LISTENING! https://www.cdc.gov/kidneyd-eare-problems.png Resources 1. https://kdigo.org/guidelines/ 2. https://www.nice.org.uk/guidance/ng203 3. https://www.uptodate.com/contents/clinical-features-diagnosis-and-treatment- of-hypertensiv- nephrosclerosis?search=hypertensive%20nephrosclerosis&source=search_result& selectedTitle=1~33&usage_type=default&display_rank=1#H3 4. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of- fibromuscular- dysplasia?search=fibromuscular%20dysplasia&sources arch_result&selectedTitl e=1~53&usage_type=default&display_rank=1 5. https://www.uptodate.com/contents/autosomal-dominant-polycystic-kidney- disease-adpkd-in-adults-epidemiology-clinical-presentation-and- diagnosis?search=autosomal%20dominant%20polycystic%20kidney%20disease& source=search_result&selectedTitle=1~65&usage_type=default&display_rank=1 More resources 1. https://www.uptodate.com/contents/overview-of-the-management-of-chronic-kidney-disease-in- adults?search=uraemia%20&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H 2. https://www.uptodate.com/contents/granulomatosis-with-polyangiitis-and-microscopic-polyangiitis-clinical-manifestations-and- diagnosis?search=granulomatosis%20with%20polyangiitis&source=search_result&selectedTitle=1~150&usage_type=default&disp lay_rank=1 3. https://www.uptodate.com/contents/anti-gbm-goodpasture-disease-pathogenesis-clinical-manifestations-and- diagnosis?search=anti%20gbmdisease&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2 4. https://www.uptodate.com/contents/anti-gbm-goodpasture-disease-treatment-and- prognosis?search=anti%20gbmdisease&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 5. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-acute-interstitial- nephritis?search=interstitail%20nephritis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Not covered S Nephrotic syndrome S Minimal change disease S Membroproliferative/mesangiocapillary GN S Membranous GN S Focal segmentaglomerulosclerosis S Post-strep GN S IgA nephropathy True or false Minimal change disease is the most common cause of nephrotic syndrome in children True Minimal change disease is the most common cause of nephrotic syndrome in children Minimal change disease S Nephrotic syndrome in children, minority of adults. S T cell and cytokine mediated damage to the glomerular basement memrane S increased glomerular permeability to serum albuminhird one episode, third frequently relapse- stopd S Selective proteinuria before adulthood S Normal glomeruli on light microscopy S electron microscopy: podocyte fusion, foot process effacement S Manage with steroids, if not cyclophosphamide Nephrotic syndrome S Primary glomerulonephritis S Minimal change GN S Membranous GN S Focal segmentaglomerulosclerosis S Membroproliferative GN S Systemic disease S Diabetes mellitus S SLE S Amyloidosis S Drugs: gold, penicillamine S Others: congenital, neoplasia, infections (endocarditis, hepatitis B, malaria)Which of these features is not a feature of nephrotic syndrome? S Hyporalbuminaemia Albumin < 20 S Proteinuria UPCR >1G/24 housr S Hyperlipidaemia S OedemaESRF O 3C O F Feedback & In +agram O N Please complete feedback to receive slides and cheat sheet!llow our Instagram page for MCQs! 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