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Renal (Acute Kidney Injury (Indications for acute dialysis (AEIOU) (A -…
Renal
Acute Kidney Injury
Definition: Rapid (<7 days) and sustained (>24 hours) reduction in renal failure causing oliguria and rise in serum urea and creatinine - usually reversible
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Pre-Renal
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Causes (Hypoperfusion) - Shock (hypovolaemic, cardiogenic or distributive) or renovascular e.g. renal artery stenosis
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Urine findings: No blood, protein, epithelial casts if severe
Renal
Causes - Acute glomerulonephritis, Acute tubular necrosis, acute interstitial nephritis, haemolytic uraemia syndrome
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Urine findings: Glomerular - Haematuria, red cell casts, protein urea; Interstitial - Proteinuria, WBC, haematuria
Post-Renal
Causes - Obstruction to outflow, can be luminal (e.g. stone), mural (e.g. tumour) or due to external compression (BPH)
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Urine findings: Haematuria (visible), WBC, abnormal cells
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Chronic Kidney Disease
Gradual, irreversible decline in kidney function
Staging
Stage 1 CKD if eGFR is >90 ml/min/1.73m^2 with demonstrable kidney damage (e.g. haematuria or proteinuria).
Stage 2 CKD if eGFR is 60-89 ml/min/1.73m^2 with demonstrable kidney damage (e.g. haematuria, proteinuria, or raised urine albumin/creatinine ratio).
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Causes: Glomerular - Primary e.g. IgA nephropathy or secondary e.g. SLE; Vascular - vasculitis and renal artery stenosis; Tubulointerstitial - amyloidosis and myeloma; Congenital - PKD, Alports; Systemic - diabetes, HTN; Developmental - vesicle-urteric causing pyelonephritis
Cx: CVS disease, Renal osteodystrophy, oedema, HTN, electrolyte disturbance, anaemia, restless legs, sensory neuropathy
Renal osteodystrophy: Sx - Reduced bone density (osteoporosis), Reduced bone mineralisation (osteomalacia), secondary/tertiary Hyperparathyroid, may get osteosclerosis ("rugby jersey spine")
Glomerulonephritis
Non-proliferative
Minimal Change Disease: Nephrotic, most common in children (idiopathic), NSAIDs
Sclerosis: FSGS (nephrotic), Nodular glomerulosclerosis
Proliferative
Sx: Haematuria, proteinuria, HTN, oliguria/renal failure
IgA nephropathy: Most common cause of GN worldwide; haematuria (hours afterURTI/GE), mesangial proliferation, IgA C3 deposits
Post-Infectious GN: Weeks after b-haem Strep infection, ASOT increased, C3 down, renal B, IgG and C3 deposits - good prognosis
HSP: Small vessel vasulitis, purpura, abdopain
Rapidly Progressive
Anti-GBM (Good Pastures Syndrome): Characterised by linear deposits of IgG on the basement membrane; In a subset of its these anti-GBM abs can cross react with antigens on the alveolar basement membrane producing pulmonary haemorrhage and renal failure
Immune complex deposition: Associated with Lupus, post-strep GN, IgA, HSP; See granular pattern of immune complex deposition
Granulomatosis with polyangiitis (Wegners): cANCA associated; get triad of necrotising granulomatous airway lesions, systemic vasculitis, pouch-immune GN
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome): pANCA (anti-MPO). Characterised by allergic asthma and eosinophilia
Microscopic polyangiitis (MPA). pANCA; Characterised by RPGN, pulmonary infiltrates - often in combination with central nervous system or musculoskeletal system abnormalities.
Nephrotic Syndrome
Triad of proteinuria, hypoalbuminaemia & oedema
Causes
Systemic disease: DM, SLE, Amyloidosis
Minimal Change Glomerulonephritis: Associated with URTI; Biopsy - fusion of podocytes; Rx: Steroids - 1% developmental end stage renal failure
Membranous nephropathy: Associated with cancers (Lung, Colon Breast), infections (SLE, thyroid disease), infections (Hepatitis B) and drugs (Penicillamine and Gold); Biopsy - Subepithelial immune complex deposits; 40% have spent remission
Focal segmental glomeruloscleorsis: More common in afro-caribbean, associated with Bergers, sickle cell, HIV; Biopsy - focal scarring, IgM deposition; Rx - steroids - 30-50% progress to end stage renal failure
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