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UCL MBBS (Fach) / Clinical conditions (Lektion)

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• z Atrial fibrillation Definition: Chaotic, irregular atrial contractions at 300-600 bpm; irregular ventricular rate; classification: acute/paroxysmal → persistent → permanentCauses: IHD, mitral regurgitation, thyrotoxicosis, peumonia, drugs (alcohol, caffeine, cocaine); Complications: Heart failure, thromboembolic eventSymptoms: Palpitations, dizzinessSigns: irregularly irregular pulseInvestigations: Bloods (FBC, U&E, clotting); ECG (absent P waves, irregular QRS complexes) Management Cardioversion: chemical (→flecanaide [not with IHD or struct. abnormalities], →amiodarone, →sotalol); DC electrical; ablation Rate-control: β-blockers (→metoprolol, atenolol), Ca2+-channel blockers (→verapamil, →diltiazem), 2nd line: →digoxin, →amiodarone Anticoagulation: →warfarin, →dabigatran; 2nd line →aspirin Maintain sinus rhythm: flecainide, amiodarone
• z Chronic heart failure Definition: Inability of the heart to meet oxygen demands of the body Classification NYHA grad 0 - IV Systolic (↓ejection fraction) vs diastolic (→ejection fraction) Left (→pulmonary symptoms) vs right (→peripheral symptoms) low-output vs high-output Causes Hypertensive heart disease IHD, incl post-MI Arrythmias, valvular disease Intrinsic: cardiomyopathy (DCM, H(O)CM, ARVCM) Cor pulmonale: COPD, interstitial lung diseae, etc. Symptoms Peripheral: pitting oedema, JVP, ascites Pulmonary: SoB, worse on lying down (→othopnoea, pillows), Paroxysmal Nocturnal Dyspnoea, frothy sputum Fatigue, dizzieness, weight loss/gain Investigations: Bloods: FBC, U&E, LFT, B-natriuretic peptide CXR: Cardiomegaly, upper lobe Diversion, peribronchial cuffing, Alveolar oedema (bat's wing shadowing), pleural Effusions, septal lines (Kerley B) ECG: evidence of ischaemia, MI, hypertrophy; Echo → ejections fraction, valves Management Lifestyle: weight loss, moderate exercise, stop smoking & alcohol Pharmacological: loop diuretic ± thiazide(-like) (for symptoms) ⇒ ACE-I (or ARB) + β-blocker (bisoprolol, carvedilol, metoprolol) ⇒ spironolactone ⇒ inotropes (digoxin) Surgical: Mechanical assist devices, transplant
• Infective endocarditis Definition: Infection & inflammation of the endothelial lining of the heart: clinicallySymptoms: Fever, pain around midrift, malaiseCauses: Bacteria: Staph aureus, strep viridans; HACEK; coxiella; chlamydia Fungi: Candida, aspergillus, histoplasma Other: SLE (Liebmann-Sachs), malignancy Diagnosis: Duke criteria major: +-ve blood culture; endocardial involvement on USS minor: fever, predisposition, immunological signs, echo Management SEPSIS 6 if indicated Empirical: amoxicillin + gentamicin Targeted: amoxacillin, flucloxacillin, vancomycin/teicoplanin, rifampicin Complications: Heart failure, emboli
• Acute coronary syndrome (ACS) Definition: Cardiac pain at rest Classification Unstable angina (trop negative) → NSTEMI → STEMI (new onset LBBB)Causes: Ruptured atheroma → thrombosis → ischaemia/inflammation; rare: emboli, vasospasms (Prinzmetal's)Symptoms:chest pain (radiating, cruhsing, exertion), SoB, sweating, tachycardia, nausea, palpitations; may be 'silent'Risk factors: Smoking, hypertension, hypercholesteraemia, diabetes, obesity, age, male, family historyInvestigations: Bloods (FBC, LFT, clotting, U&E, cardiac enzymes (trop, LDH; repeat at 12h)); CXR, ECG (inverted T waves, ST elevation/depression, LBBB); angiogram / contrast CT Management Acute drugs: Morphine, ±Oxygen, Nitrates, Aspirin+clopidogrel, LMWH if not for PCI PCI if possiblle for STEMI or if high risk Thrombolysis if <12h after onset, and PCI not possible within 2h Long term: As for →IHD DDx: PE, pericarditis, aortic dissection, oesophagitis/reflux
• Transient ischaemic attack (incl ABCD2) Definition: Sudden onset of focal neurological symptoms with presumed vascular cause; complete resolution of symptoms within 24h Aetiology: Thrombotic / thromboembolic; cardiovascular risk factors (hypertension, diabetes, smoking, hyperlipidaemia; AF) Symptoms: Weakness, numbness / parasthaesia, facial droop; vision loss (amurosis fugax) Management: A(≥60)B(≥140/90)C(speech/weakness)D(0/10/60; diabetes)2 score: same day referral if ≥ 4 (moderate) Aspirin 300mg PO OD until further evaluation, then reduce to 75mg PO OD Adress modifiable risk factors (WAFFLES, meds, endarterectomy)  Investigations: CT head, ECG, carotid Doppler →stroke, ACS, IHD, vascular dementia; giant cell arteritis
• Stroke - cerebral infarction - apoplexy Definition: Sudden onset of focal neurological deficits with presumed vascular cause, not resolving within 24hrs. Classfication (by cause): thrombotic, thromboembolic, haemorrhagic; rare: watershed (sudden BP drop), carotid dissection, vasulitis Territories: MCA, PCA, PICA, cerebral, brainstem, lacunar (ASPECTS); clinically anterior vs posterior circulation (Oxford) Symptoms: Mostly negative symptoms; no spreading Crossed symptoms → brainstem lesion, e.g. PICA Only motor symptoms → lacunar (internal capsular from MCA→lacunar arteries): also pure sensory, ataxic hemiparesis, clumsy hand dysarthria syndrome (→slurred speech) Risk factors: Smoking, diabetes, hyperlipidaemia, age, male, heart disease, CV disease Causes: hypertension, cardiac source, prothrombotic state (thrombophilia, anti-phospholipid syndrome), CAS, vasculitis, hyperviscositiy, thrombocytopenia, etc. Management: Stabilse: airway, glucose, BP (lower slowly) Imaging: CT, MRI Thrombolysis: alteplase Antiplatelets (CI haemorrhagic): →Aspirin (300mg, then 75mg)+ →dipyridamole; →Clopidogrel; antidysrhtyhmics; →warfarin for embolic stroke or AF Stroke unit, rehabilitation, MDT input Carotid Doppler, 24h ECG 2ary prevention →TIA (ABCD2), ACS
• Cranial nerve lesions Classification by nerves I (olfactory): trauma, chemicals, Parkinson's, Kalman's II (optic): optic neuritis, visual field defects, amurosis fugax III (oculomotor): post comm artery aneurysm (→aortogram, cerebral angiogram); diabetes, vasculitis, MS (→INO) V (trigeminal): neuralgia, cavernous sinus thrombosis (III, IV, Va,b) VI (abducens): intracranial pressure VII (facial): Bell's pasly, carotid tumour VIII (vestibulo-ochlear): acoustic neuroma, Ramsey-Hunt II On Examination: Cerebellar signs: nystagmus, square wave jerks, correcting saccades False localizing signs: lateral gaze pasly Brain stem signs: Lateral disasocciation (PICA, vertebral artery) Horner's triade? DDx for ptosis: uni- vs bilateral, pupil? → higher cognitive functions (memory, praxis, speech, estimation)→ Parkinson's exam, speech exam, AMT
• Dementia Definition: Progressive deficits in multiple cognitive domains Symptoms: positive: wandering, aggression, flight of ideas, logorrhoea negative: apathy, mood disturbace, impaired memory Personality changes, disinhibition, episodic / visuospatial memory Diagnosis: Collateral history, timeline of symptoms Dementia screen, e.g. AMTS mental & physical examination Commonest causes:: Vascular (multi-infarct) Lewy Body Fronto-temporal Differential diagnosis: Hypothyroidism B12 / folate / thiamine deficiency Tumours Parkinson's Normal pressure hydrocephalus Management: Coordinaed care, respite care, capacity? AChE-inhibtors for Alzheimer's Avoid neuroleptics, tricyclics, sedatives etc.
• Functional neurological disorders Other terms: conversion disorder, hysteria Symptoms: Weakness, paralysis Paraesthaesia Blindness, hearling loss Cause Stressful event, no organic cause found DSM-V: somatofom; ICD-10: dissociative See also: Somatisation Pathologial illness behaviour
• Guillain-Barre syndrome Definition: Postinfective (campylobacter (→clarythromycin), CMV, EBV etc.) acute autoimmune demyelinating polyneuropathy, mostly motorSymptoms: Proximal ascending weakness, e.g. respiratory depressionMangement: Ventilation if needed, immunoglobulins, plasma exchange; no steroids  10% mortality → Miller-Fisher: cranial nerve analogue; CIDP (→plasmapheresis, IV-Ig)
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• Intracranial tumours Classification: Primary vs secondary ("brain mets") malignant vs bening by tissue type: astrocytoma, meningioma, etc Symptoms: Focal neurology, depending on size of tumour Complications: increased intracranial pressure Hernatiation / coning DD: Abscess, cyst
• Spinal tumours Classification: Primary non-lymphoproliferative: rare (5%) vs metastatic - common Benign vs malignant By tissue type: bone, cartilage, etc Symptoms: Local: Pain Regional: neuroligcal deficits: weakness, parasthaesia, sphincter control Systemic: Fatigue, weight loss Diagnosis: Bloods (↑Ca2+?), imaging (whole spine MRI, staging CT) Management: Surgery, radiation, chemotherapy
• Migraine Aura slow onset, dying off visual, aural, sensitive Hypersensitivity photophobia phonophobia mechanic Triggers: Break of routine, hunger, chocolateTreatment (preventive, don't overuse!) paracetamol anti-inflammatories triptans → selective serotonin agonists (suratamin)
• Motor neuron disease Definition: Degenerative selective loss of neurons in motor cortex, CN nuclei, or anterior spinal horns. Diagnosis: Examination: upper & lower motor neuron signs, e.g. wasting + brisk reflexes Investigations: Bloods, MRI, lumbar puncture, EMG, muscle biopsy DD: trapped nerve, peripheral neuropathy, MS Examples: Amyotrophic lateral sclerosis (ALS), primary lateral sclerosis, progressive muscular atrophy, progressive bulbar palsy, pseudo-bulbar palsy spinal-bulbar muscular atrophy (Kennedy's): perioral fasciculations, gynaecomastia Post-Polio Management: (referral to palliative care) Conservative: MDT (PT, OT, speech and swallowing, dietician, social services); air mattress Medical: symptomatic (baclofen, hyoscine) Associated with →frontotemporal dementia
• Multiple sclerosis Pathology auto-immune demyelination in CNS Classification: relapsing/remittent, primary progressive Symptoms: Optic neuritis, autonomic neuropathy, peripheral neuropathy Diagnosis:clinical; lessions dissemniated in time and space Management: immunosuppression: steroids, antibodies, →azathioprine, palliative    
• Myasthaenia gravis Aetiology: Autoimmune; Deacativating auto-antibodes to post-synaptic ACh receptors in NMJ Symptoms: Weakness (starting proximal EOM → bulbar → face → neck → limb girdle, trunk); fatiguability, ptosis Can affect: speech, breathing, periphery Signs: Fatiguability: count down from 50 Diagnosis: Clinical picture Antibodies Edrophonium test EMG → positive decrement CT of thymus Improved ptosis after ice DD: polymyositis, SLE, Takayasu's, botulism, 1ary myopathy Management: AChE, e.g. pyridostigmine (treat pro-cholinergic side-effects) immunosuppression: prednisolone, azathioprine, methotrexate intravenous immunoglobulins before thymectomy See also: Myasthaenia crisis Lambert-Eaton syndrome (paraneoplastic from SCLC; ABs agains presynaptic VGCCs)
• Myopathies --
• Nerve root compression Definition: Mechancal radiculopathy, due to e.g. disc prolapse, vertebral fracture, infection, abscess Symptoms: Common:Unilateral pain (e.g. sciatica: sharp, buttocks and back of leg) and weakness Red flags: <20 / > 55yrs, B-symptoms, malignancy, night pain, bilateral neurological symptoms incl sphincter, thoracic pain Signs: Myotomal weakness, dermatomal pain; positive straight leg (L4,L5, S1) / femoral stretch test (L2,L3,L4) Management: Education, analgesia, physiotherapy; if red flags → urgent neurosurgical referral
• Cauda equina syndrome --
• Organic causes of psychiatric disorders --
• Parkinson's disease Idiopathc vs Parkinson+ Drug-indued Parkinsonism Parkinson + syndromes Lewy body dementia - drop attacks and neuropsychiatric symptoms PSP - vertical diplopa MSA - autonomic eatures & ataxia CBD Symptoms: Tremor, rigidity, bradykinesiaManagement Drug treatment D2 agonists: pramipexole, ropinirole; ergot derivatives (bromocriptine, apomorphine, cabergoline) not used due to side effects L-DOPA + carbidopa/benserazide (+ domperidone) MAO-B-I: selegiline, rasigiline COMT-I: entacapone, talcapone antagonistic pathway: benzatropine, procyclidine for drug-induced Other treatment Surgical: DBS in STN, lesion in GPI (pallidotomy) cell transplant, gene therapy, stem cells, amantadine → Alzheimer's, normal pressure hydrocephalus
• Peripheral neuropathy Definition: Damage to peripheral nervesClassification Demyelinating vs axonal Chronic vs acute Sensory (diabetes, ESRF) vs motor (GBS, lead, CMT) vs mixed Symptoms: (Often length-dependent) sensorimotor-loss, glove-and-stocking distributionSigns: Decreased peripheral sensation, tone, power, reflexesCauses: Diabetes, autoimmune (CIDP), B12 deficiency (e.g. alcohol), vasculitis → mononeuritis multiplexManagement (MDT) Physio and foot care Steroids (for vasculitic causes) Neuropathic pain: amitriptyline, gabapentin, pregabalin → autonomic neuropathies (e.g. gastroparesis in MS), cranial neuropathies (e.g. Miller-Fisher)
• Autonomic neuropathy Symptom of Multiple Sclerosis, diabetes and many other conditions Can affect all systems → good S/R! Bladder (→ oxybutynin) Bowel dysfunction, gastric paresis Arrythmias Postural hypertension Dry mouth
• Seizure disorders Definition: Clinical correlate of excess synchronized electrical discharge in a part or the whole of the brain Classification Tonic-clonic, absence Focal vs generalized Simple vs complex Management Drugs: sodium valproate, levetiracetam, carbamazepine, ethosuximide; lamotrigine impact on life: driving etc → Epilepsy, → febrile convulsions in children, → syncope
• Spinal cord compression Causes: Metastases (prostate, breast, lung); lymphoma; crush fracture; abscessSigns / symptoms Bilateral neurology in the legs: weekness, paraesthesia, numbness Saddle anaesthesia Reduced sphincter tone / faecal incontinence Urinary retention Management Investigate: Do a PR / breast exam, Ca2+, PSA, CT CAP, full spine MRT Medical: Steroids, e.g. dexamethasone Palliative radiotherapy Neurosurgical referral for surgical decompression
• Headaches History SOCRATES for pain DDx Acute single: Meningitis, trauma (sub-, extradural haemorrhage), venous sinus thrombosis, sinusitis, malaria, glaucoma Recurrent: Migraine, cluster, trigeminal neuralgia, recurrent meningitis Subacute onset: Giant cell arteritis Chronic: Tension, IIH, medication overuse, hemicrania continua (indomethacin responsive headache) Worrying Sudden onset (thunderclap) → subdural haemorrhage Pressure-related: worse on lying down, Valsava ↑ Temperature + neck stiffness → meningitis Management Pain relief Treat underlying cause →Migraine, →Cluster, →Tension
• Adrenocortical insufficiency Definition: Inability of the adrenal cortex to produce sufficient glucocorticoids (zona fasciculata), mineralocorticoids (zona glomerulosa) or sex hormones (zona reticularis)Causes: 1ary: Addison's (idiopathic AI, TB), Wh-F (bleeding, e.g. with DIC); 2ary: panhypopituitism, iatrogenic ACTH suppressionSymptoms: Fatigue, abdominal pain, nausea, vomiting, dizziness, headache; lean, tanned appearance; depression/psychosisSigns: low BP, ↓Na+, ↑K+ , hyperpigmentation (only in 1ary due to ↑ACTH)Investigations: Bloods (U&E, ACTH, aldosterone, renin), short ACTH (synacthen) stimulation test → measure cortisolManagement: Steroid replacement: 15-25mg hydrocrotisone + 50-200mcg fludrocortisone Advice: steroid card, doctors aware, emergency syringes
• z Adrenocortical excess →hyperaldosteronism →Cushing's syndrome
• Diabetes, type I Definition: Autoimmune destruction of pancreatic β-cells Epidemiology: Symptoms: Polyuria, polydipsia, DKA (abdo pain, lethargy), weight loss Signs: elevated BM, ketonuria/-aemia, acidosis (pH < 7.3), Kussmaul breathing Management: DKA according to protocol (treat shock, saline 10ml/kg, insulin 0.1unit/kg/hr, 5% glucose 125ml/hr if BM < 14 or falling quickly, keep insulin to switch off ketone production) Long term: insulin, e.g. basal bolus, or biphasic Advice: (also refer to diabetes nurse specialist and dietician) Hypos: autonomic (irritability, hunger) and CNS (drowsiness, headache) features; "4 is the floor" Screening: Eyes, feet Other: illness, holidays, swimming/boating/climbing etc → Type II diabetes
• Diabetes, type II Definition: Syndrome of relative insulin deficiency and resistanceCauses: Metabolic syndrome, obesity; Cushing's, steroids/antipsychotics, pancreatic damageSigns and symptoms: Polyuria, polydipsia, recurrent infections, retinopathyDiagnosis: BG > 11.1 mmol/L (random / OGTT 2h) or > 7.0 mmol/L (fasting), x2, or symptomatic x1Complications: Neuropathy, nephropathy, retinopathy; MI, CVAManagement (MDT) Conservative: Diet, exercise, weight loss Medical: Glycaemic control (Metformin, sulphonylurea, ... , insulin), risk factors (statin, ACE-I) Screening: retinal, foot care → type I DM, IFG, IGT; hypoglycaemia
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• Diabetes insipidus Definition: Large volume of dilute urine due to impaired water reabsorption Symptoms: Polyuria, polydipsia, dehydration, hypernatraemia Diagnosis: Water deprivation test Causes Cranial (ADH deficiency): congenital, tumour (Langerhans cell histiocytsis, germinoma), infection, vascular, trauma, infiltration nephrogenic (ADH insensitivity): congenital, drugs (lithium), metabolic (low K+), post-obstructive Management: Emergency: Desmopression Treat underlying cause
• Diabetic emergencies Hypoglycaemia Hyperglycaemia HONK - HHS DKA Pathophysiology Management Prevention
• Disorders of Calcium metabolism Correct: Ca2+ + 0.025*(40-Alb); Physiology Hyper (management: fluids, bisphosphonates; symptoms: stones, bones, moans, groans) Malignancy: Myeloma, any cancer (in particular one mets) Endocrine: 1ary hyperparathryroid Drugs: e.g. thiazides CKD → renal osteodystrophy Sarcoidosis, dehydration Hypo Causes: Classify by PO32- Symptoms: SPASMODIC, incl Trousseau's and Chvostek's signs Tx: Replacement +/- vit D at right activation
• Endocrine emergencies Addison's → fludrocortisone / hydrocortisone → adrenal insufficiency Thrytoxicosis → carbimazole → hyperthryroidism Myxodoema → levothyroxine → hypothyroidism Phaeochromocytoma → adrenoreceptor blockade → Multiple Endocrine Neoplasia Pituitary failure (Sheehan's) →??
• Gonadal dysgenesis Aplastic gonads, e.g. Turner's syndrome (45 XO, → aortic coarctation, bicuspid aortic valve)
• Lipid metabolism disorders (Familial) Hypercholesterolaemia (FH): senile arcus, tendon xanthomata (Familial) Hypertriglyceridaemia (Familial) Combined Hyperlipidaemia (FCH): most common Tangier disease: Familial α-lipoprotein deficiency: reduction in HDL A-betalipoprotein-aemia Predisposiitons Diabetes Cardiovascular disease Diagnosis: Cutoff values & family historyManagement: Statins (cholesterol) or fibrates (triglycerides) Referral to lipid specialist
• Pituitary and adrenal tumours --
• SIADH Definition: Syndrome of Inappropriate ADH secretion, diagnosis by exclusionSigns: euvolaemic hyponatraemia → various, e.g. neurological, confusionCauses: Central: CNS Infections, stroke, subarachnoid/-dural haemorrhage Drugs: SSRI's, carbamazepine, tricyclics; sulfonylureas Malignancy: small-cell carcinoma of lung (ectopic production); prostate Management: Hypertonic saline (3%) Treat underlying cause → hypo-/eu-/hypervolaemic hyponatraemia
• Thyroid cancer Types Papillary: 60%, spread vie nodes / lung Follicular: <25%,haematogenous spread Medullary (calcitonin, MEN→phaeo screen) Lymphoma Anaplastic Symptoms: HyperthyroidismInvestigations: TFT, α-TSHR, CXR, USS, nuclear medicine, FNA (if follicular, refer to surgery)Management: Medical: Ablation Surgical: Thyroidectomy + replacement; classical complications (hypoparathyroidism, recurrent laryngeal nerve, bleeding, infection) →DDx for thyroid lump; DDx for neck lump
• Hyperthyroidism / Thyrotoxicosis Causes: Primary: Grave's, transient thyroiditis (e.g. Hashimoto's), drugs (e.g. amiodarone), toxic nodule Secondary: pituitary adenoma → TSH; Hθ → TRH Symptoms: Tremor, anxiety, sweating, weight loss, agitationSigns: Goitre, tachycardia, AF, thyroid eye diseaseInvestigations: Blood: Thyroid Function Tests Imaging: USS (cold), technetium uptake (warm/hot)  Treatment Symptomatic: Propranolol Antithyroid drugs: Carbimazole, propylthiouracil Surgery: thyroidectomy, radioactive iodine therapy
• Hypothyroidism Definition: Decreased blood levels of T3, T4 Symptoms: Weight gain, tiredness, loss of appetite, wandering around, dementia, constipation, etc Signs: bradycardia Diagnosis: TFT, increased TSH in primary Causes: 1ary: iodine deficiency; AI: primary atrophic hypothyroidism, throiditis (e.g. Hashimoto's); thyroid cancer; thyroidectomy; drug-induced (→lithium, →amiodaraone) 2ary: Hypopituitarism (e.g. Sheehan's post-partum) Management: →Levothyroxine
• z Acute kidney injury Definition: Decrease in kidney function over 48h: eGFR > 50% or creatinie > xx from baseline Causes: decide based on urine electrolyte profile Prerenal: Stenosis + ACE-I, shock (hypovolaemia, septic, cardiogenic, ...) Intrinsic: ATN due to ischaemia, toxins (ABx, NSAIDS, contrast), GN, interstital nephritis, myeloma, or vascular (vasculitis, ↑BP, HUS, TTP) Postrenal: obstruction (stones, cancer, urethral strictures, ...) Symptoms: none; or oligo-,anuria, loin painSigns: oliguria, confusion, crackles, ↑K+, ↑urea, ↑creatinineInvestigations: Bloods (FBC, U&E, LFT, clotting, ESR/CRP; autoimmune scan); urine dispstick; ECG; CXR; renal ultra soundManagement Assess fluid status Stop nephrotoxic medication Correct electrolyte abnormalities: Hyperkalaemia → insulin+glucose ± calcium gluconate Manage complications: fluid overload → pulmonary oedema, hyperkalaemia, metabolic acidosis, bleeding Get help, ?acute dialysis (K+>7, pH<7.2), refractory pulmonary oedema, uraemic enephalopathy
• z Nephritic syndrome Definition (clinical): Haematuria w/ RBC casts + proteinurua + hypertension; progressive oliguria and renal impairmentCauses: IgA nephropathy (Berger's) & Henoch-Schoenlein, lupus nephritis, α-GBM disease (Goodpasture's), proliferative and rapidly progressive (→crescenteric) GNManagement: Refer to nephrology Control BP < 130/80 or 125/75 if proteinuria > 1g/d ACE-I and ARB
• Bladder and urothelium cancers Types: Transitional cell ; 90% associated with aniline dyes ; Squamous cells: schistosoma haematobium Staging: TNM Symptoms: painless haematuria, retention Investigations: Urine dipstix (micropscopic haematuria, cytology), cystoscopy+biopsy, CT KUBStaging: TiS-T4Tx: Chemotherapy (BCG irigation), radiotherapy, surgery (⇒ urostomy)F/U: Hx, examination, cystoscopy
• Chronic kidney disease Definition: Kidney damage for >3months: abnormal structre,function, or GFR (<60ml/min)Classification: 5 stages based on eGFR: >90, 90-60, 60-45-30, 30-15, <15; Stage I-II only with functional or anatomical abnormalityCauses: DM, hypertension, glomerulonephritis, polycystic kidney, nephrotoxins, renal vascular disease etc. History: UTI, BP, DM, family history, drugs; fatigue (anaemia), weakness, anorexia, pruritus, metallic taste, etc. Investigations: UnE's, LFT's, urine diptstix & microscopy; USS; biopsy Complications: Cardiovascular disase: statins, low-dose aspirin Anaemia: → erythropoietin Renal bone disease: Calcium binders, vit D supplements Oedema: → frusomide Restless legs: →clonezepam Management: Manage complications Altered prescriptions → ESRF / RRT
• Glomerulonephritis --
• z Hypertension Definition: systolic/diastolic BP > 180/110 (imediate treatment), 140/90 (target), 130/80 (target in diabetics with end-organ dysfunction), 125/75 (nephritic with proteinuria > 1g/d)Symptoms: --; Signs: risk factor for CV disease (MI, stroke)Complications: eyes (hypertensive retinopathy I-IV), brain, heart, kidney ⇒ urgent treatment; papilloedema ⇒ malignant hypertensionCauses: 1ary ≅ essential ≅ idiopathic 2ary: coarcation of the aorta; renal: RAS, nephritic; adrenal: phaeochromoctoma, hyperaldosteronism (Conn's), Cushing's; other: sleep apnoea  ⇒ treat underlying cause pregnancy Investigations: repeat measurements, ABPM; urine dipstick, renal artery bruit/US/MRA; aldosterone/renin ratio; 24h catecholamines; 24h cortisol, cortisol+ACTH, dexamethason (8mg) suppression; CT/MR imaging of adrenals, nuclear medicine scan, venous sampling Management (of 1ary): Essential Ca2+ blockers (=C): amlodipine* ACE-inhibitors (=A): ramipril → flash oedema w/ bilateral RAS Thiazode diuretics (=D): chlortalidone, indapamide Aldosterone antagonists: spironolactone β1-blockers: atenolol; α1-blockers: prazosin; K+ channel openers: diazoxide; α2/I1-agonists: clonidine; other: renin inhibitors, etc. --- Pregnancy: Labetalol, methyldopa, hydralazine, felodipine Accelerated: Labetalol, hydralazine, amlodipine Surgery: Renal sympathectomy
• Kidney cancer RCC ⇒ haematuria, varicocele, polycythaemia etc Wilm's (WT 1,2 tumour suppresor genes)
• Microscopic haematuria ?Cancer ⇒ imaging (cystoscopy, CT KUB) ?Stone ⇒ USS or CT +/- contrast
• z Nephrotic syndrome Definition (clinical): proteinuria (>3g/d), hypoalbuminaemia, oedema; also severe hyperlipidaemia Causes: (leaky glomerular basement membrane; check pathology) Minimal change (most common in kids) Membranous GN Mesangio-capillary GN Focal-segmental glomerulosclerosis thin basement membrane nephropathy Complications Infections (loss of immunoglobulins) → prompt treatment Thromboembolisms (loss of antithrombin III) → LMWH prophylaxis Hyperlipidaemia → statin if persistent Diagnosis: Dipstick (protein, glucose, nitrates, WCC), bloods (FBC, U&E, LFT, clotting), imaging, biopsy Management: Steroids; treat underlying cause & complications; BP target < 125/75 if proteinuria > 1g/d → ACE-I & ARB

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