Abdomen Flashcards
Midline laparotomy scar in a renal tx patient?
SPKT (usually younger T1DM patients)
Side effects of immunosuppression in transplant patients
Tremor
Gum hypertrophy
Dyslipidaemia
HTN
Hypertrichosis (ciclosporin)
Diabetes (CNRI) - NODAT
Opportunistic infections
Skin cancer
Steroids: osteoporosis, easy bruising, cushingoid features, proximal myopathy, cataracts
MMF: GI symptoms
SE of chronic immunosuppression in general
Opportunistic infections
PTLD
Skin malignancies
Viral warts
Renal tx and hearing aids?
Alport’s syndrome
Renal tx scar, b/l ballotable kidneys and nephrectomy scar?
ADPKD
Non-scarring alopecia, oral ulcers, malar rush, young femal patient, CKD/renal tx?
SLE
Features on clinical exam of a patient with ESRD secondary to diabetic nephropathy
Finger prick marks
Free style Libra device
diabetic dermopathy
Foot ulcers/amputations
What are the main causes of ESRF?
Diabetic nephropathy
Hypertensive nephropathy
ADPKD
Glomerulonephritis
Drugs: cyclosporine, NSAIDs, aminoglycosides
Autoimmune: SLE, RA, GPA, eGPA
Reflux nephropathy / recurrent UTI
Alport’s syndrome
Order when presenting a transplant case
“This is a patient who has evidence of previous ESRD (Secondary to X if known) with a renal transplant as evidenced by a J-shaped scar in the RIF with an underlying firm, palpable, non-tender mass. The transplant appears to be functioning. Previous modes of RRT include X as evidenced by Y. There are/are not any signs of immunosuppressant toxicity. This patient does not appear clinically overloaded and there are no signs of suggestive of uraemia.
There were no specific signs pointing to a specific aetiology, possible differentials include…”
1) esrd +/- aetiology
2) transplant
3) evidence of above
4) tx functioning?
5) prev modes of RRT
6) Complications: immunosupp tox, fluid, uraemima
7) signs suggestive of aetiology
How would you like to complete your examination in a renal patient?
“To complete my examination I would like to measure the blood pressure, perform urinalysis and do a full fluid assessment”
Signs of graft failure
Reduced UO
Tenderness over graft
Fever
Features of uraemia
Increased fluid retention
Rise in creatinine
Nephrectomy indications in CKD pt
Room for new kidney
Recurrent infections of cysts / haemorrhage / pain
What to do if you see an AVF?
Inspect for recent needling, palpate for thrill, auscultate for bruit
If scar in iliac fossae but no palpable mass, cause?
Transplant nephrectomy or not working anymore (look for signs of active RRT)
What to look for in the face, neck and chest of a renal patient?
Corneal arcus (CVS risk, CNRIs)
JVP for fluid status
Scars in neck for lines
Parathyroidectomy scar ? tertiary hyperparathyroidism
WHy may a CKD patient have a horizontal scar in the anterior neck?
Parathyroidectomy from tertiary hyperparathyroidism
Modes of HD
AVF
AV graft
Tunneled CVs
Non-tunneled CVCs
(in order of preference)
Clinical signs which help determine adequacy of RRT
Asterixis (uraemic encephalopathy)
Volume status
Excoriations (pruritis from uraemia)
Tachypnoea (resp compensation from metabolic acidosis)
Pericardial rub (uraemic pericarditis)
Complications of ESRF
Renal anaemia
Tertiary hyperparathyroidism
Volume overload
Metabolic bone disease (renal osteodystrophy)
CVS risk
Acidosis
Uraemia complications: loss of appetite, encephalopathy, pericarditis
Electrolyte impairment (hyperkalaemia)
CRFHEALSU
CVS
Renal osteodystrophy (phosphate binders, activated vitamin D)
Fluid OD
HTN
Electrolyte disturbance
Acidosis, Anaemia
Leg restlessness
Sensory neuropathy
Uraemia complications
Treatment for renal anaemia
Iron and EPO
Renal transplant complications
Early: acute graft dysfunction
Late: drug toxicity, immunosuppression SE, opportunistic infections, cancer, NODAT
Recurrence of original disease
CVS disease
What should renal tx patients be followed up for annually
Malignancy
CVS disease
drug toxicity
Indications for urgent dialysis
Acidosis, electrolytes (refractory hyperkalaemia), fluid overload, uraemia (pericarditis or encephalopathy), overdose/toxicity
At what stage refer pt for RRT?
Depends on kidney failure risk equation, NICE guidelines on urgency of referral based on their score
(generally CKD 4-5, eGFR <30 or rapidly progressive, ideally to be seen > 1 year prior to needing RRT)
Complications of AV fistula
Infection
Haemorrhage
Thombosis
Stenosis
Aneurysm
Steal syndrome
High output cardiac failure
Failure to form
How to differentiate between a kidney and a spleen on exam
Kidney:
does not move with respiration
Ballotable
Can get above it
Spleen
Cannot get above it
Notch
Moves with respiration
What investigations would you do for renal tx pt coming in on the take?
Obs: BP, temp
DRUG CHART FOR NEPHROTOXIC AGENTS
BM
Urine: dip for glucose, protein and blood
VBG: Acidosis? electrolytes? Hb?
ECG: ?Pericarditis (ST depression and saddle elevations)
Bloods: FBC (renal anaemia, infection), UE, bone profile, hba1c, CRP, iron/b12/folate, vitamin D, PTH
FUll septic workup if febrile
Tacrolimus levels, ACR
Viral: PCP, CMV, BK, EBV, Fungal markers, JC vius
CXR: Fluid OD
Imaging: transplant USS +/- doppler
Special tests
- Renal biopsy to investigate graft deterioration
Management of renal tx patients
MDT approach
Patient education on risk factors, medication compliance, modifying CVS risk factors (smoking cessation), when to seek hospital support
Sun screen
Monitor for immunosuppressant toxicity
Ensure attends cancer screening and skin cancer checks
Acute presentations with infections to be treated as per sepsis guideliens
Initiate RRT if graft function despite appropriate immunosuppression
standard immunosuppressant regimen for renal tx
CNI, MMF, steroido
Contraindications to renal tx
Active cancer
Active drug use
active infection
Uncontrolled psychiatric disorder
Obesity
Lack of suitable donor
Severe comorbidity
Examples of glomerulonephritis which cause ESRD
IgA, FSGS, membranous nephropathy
Which viruses to screen for in renal tx pts in hospital
CMV, BK, EBV, JC, HSV
Renal tx pt with sclerodactyly, bird beak nose, microstomia
Systemic sclerosis
Renal tx + rheumatoid hands, nodules
RA
Renal + liver tx
? CNI toxicity
Gum hypertrophy DDx
Drugs: ciclosporin
Scurvy
AML
Familial
Assessment of a pt prior to renal transplant
Virology: CMV, Hepatitis, VZV, HIV
ABO
Anti-HLA antibodies HL DR > B > A
Assess comorbidities (assess CVD)
Types of kidney donor
DBD
DCD
Live (Related and unrelated)
Types of rejection
Hyperacute (mins)
Acute < 6mo
Chronic > 6mo
General dialysis complications
CVS disease
Malnutrition
Infection
Psychosocial
Amyloidosis
Renal cysts
What is steal syndrome?
Distal ischaemia on side of AVF
Which bloods to send for SLE?
ANA, C3,C4
Commonest cause of death in systemic sclerosis
Renal crisisW
What does a SS renal crisis constitute
Malignant HTN, acute renal failure
Mx: ACEi
DDx bilateral renal enlargement
ADPKD
Bilateral hydronephrosis
Bilateral renal cell ca i.e. VHL
Tuberous Sclerosis
Amyloidosis
DDx unilateral renal enlargement
ADPKD
Hydronephrosis
Renal cell ca
Renal hypertrophy
What may a renal bruit heard over a transplanted kidney suggest?
Renal artery stenosis
Serious SE of azathioprine
BM suppression (check TPMT levels prior to commencing)
Complications of ADPKD
Renal:
Pain
Infection of cysts
Hypertension
Cyst haemorrhage and rupture
Extra-renal:
Cysts elsewhere: spleen, liver, pancreas
Berry aneurysms and stroke
MVP, aortic root dilatation, dissection
Colonic diverticulae
Neurological complication of CKD
Sensory neuropathy
Types of ADPKD and chromosomes
PKD 1 gene (Type 1) - Chr 16 (85%)
PKD 2 gene (Type 2) - Chr 4
Name some renal cystic disordersA
ADPKD
VHL
TS
VHL genetics
Autosomal dominant, tumour suppressor gene
TS genetics
AD, TSC1 and TSC2
How may an ADPKD patient present? (renal signs/symptoms)
Pain
Mass
Recurrent UTI
Macroscopic haematuria
Proteinuria
Renal failure/ CKD
HTN
Renal stones
Non-renal signs and symptoms in an ADPKD patient
Berry aneurysms/ SAH
Cardiac complications: MVP, aortic root dilatation, aortic dissection
Cysts elsewhere
ADPKD diagnostic classification name
Ravine Pei
Outline the Ravine Pei diagnostic classification of ADPKD
< 30 - 2 cysts in either kidney
30 - 59 2 cysts in each kidney
> 60 - 4 cysts in each kidney
Diagnostic investigation for ADPKD
USS
Which mode of dialysis is avoided in ADPKD?
Peritoneal dialysis due to risk of infection
Extra renal features on examination of an ADPKD patient
Hemiparesis
Liver cysts/ irregular liver edge
Craniotomy scar
Nephrectomy scars
Why may an ADPKD patient have loin pain?
Mass effect
Renal stones
Cyst infection, rupture, haemorrhage
UTI
Which renal cystic conditions are at high risk of neoplastic transformation?
VHL and TS
Investigations for an ADPKD patient
History - FH, intracranial aneurysms, heart disease etc
Obs - BP, urine dip and urinalysis
ECG
Bloods: FBC, UE, LFT, Bone profile (renal bone disease)
Imaging: CXR (fluid OD), Renal USS
Offer genetic testing
Management in ADPKD
MDT: nephrologist, specialist nurses, geneticists/counsellors, dietitian, GP
Non-pharmacological: patient education, referral to support groups, dietary advice (low salt and protein), family genetic counselling, avoiding nephrotoxic agents, minimising CVS Risks
Medical: Treatment of co-existing complications like HTN, infection
Tolvaptan can slow cyst growth
Dialysis
Surgical: Nephrectomy alone, renal transplant +/- nephrectomy
What is the Bosniak system?
Classification system used classify the malignant risk of renal cysts based on CT findings
How would you complete your examination in suspected ADPKD patient?
History (FH)
Obs (BP, temp)
Urine (protein, haematuria, leukocytes)
CVS examination for MVP/MR
Neurological examination if concerns of Berry aneurysms
DRE - Association with diverticular disease
When examining ADPKD, signs to look for/ important negatives
Evidence of CKD, CLD
Current dialysis modes/ renal transplant
Fluid status
Evidence of uraemia
Neurological deficits
What % of those > 60 with ADPKD have berry aneurysms
20% (5% in < 60)
What ix would you do if suspecting cerebral aneurysms?
MRA
Indications for nephrectomy in ADPKD
Pain
Cyst rupture and haemorrhage
Recurrent infection
Space for tx
Suspected malignancy
Von Hippel Lindau features
Spinocerebellar haemangioblastomas (ataxia)
Bilateral renal cell carcinoma/ cysts
Retinal haemangioblastoma
Bilateral hydronephrosis
Tuberous sclerosis features
Ash-leaf macules
Shagreen patches
Adenoma sebaceum
Ungal fibromas
Retinal hamartomas
Renal angiomyolipoma
Renal cysts
Epilepsy (80%)
Learning difficulties/ autism
Cardiac rhabdomyomas
Lung lymphangiomyomatosis (LAM)
Renal angiomyolipoma
Epilepsy
Tuberous sclerosis
Skin features in TS
Shagreen patches
Subungual fibromas
Adenoma sebaceum
Ash-leaf macules
Alport syndrome features
Bilateral sensorineural deafness
Non-visible haematuria
Proteinuria
CKD
Tolvaptan MOA
Vasopressin receptor 2 antagonist
Why do patients with tuberous sclerosis develop renal cystic disease?
TSC2 gene on chromosome 16 next to the PKD1 gene and as such they can develop manifestations of both diseases
Systems to examine if suspecting tuberous sclerosis
Skin + nails
Kidneys: tremor, any RRT, transplant or nephrectomy scars, enlarged kidneys, CKD complications
Lungs: lymphangiomyomatosis
Heart: cardiac rhabdomyomas
Eyes: fundoscopy
Neurology
TS DDX
NF1
VHL
Best modality to look at ash leaf macules
Wood’s lamp to view depigmented patches
