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Year 3 OSCE > Case 22- CKD > Flashcards

Case 22- CKD Flashcards

1
Q

Causes of proteinuria

A

CKD
Physical exercise
Fever
Pregnancy
UTI
Hypertensive emergency (renal damage)
Nephritic/ nephrotic syndrome

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2
Q

Urinary protein

A

NICE recommend using the albumin:creatinine ratio (ACR) in preference to the protein:creatinine ratio (PCR)

Should be a first-pass morning urine specimen
if the initial ACR is between 3 mg/mmol and 70 mg/mmol, this should be confirmed by a subsequent early morning sample. If the initial ACR is 70 mg/mmol or more, a repeat sample need not be tested.

NICE guidelines state ‘regard a confirmed ACR of 3 mg/mmol or more as clinically important proteinuria’

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3
Q

Metabolic complications from CKD

A

CKD mineral bone disease- hypocalcaemia and hyperparathyroidism (vitamin D analogue)
Renal anaemia (EPO and IV iron- target ferritin over 200 in CKD)
Metabolic acidosis (sodium bicarbonate)
Hyperkalaemia (dietary restriction and consider reduction if ACE-I)

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4
Q

Azotaemia

A

Elevation of nitrogenous metabolic waste in the blood due to failure of clearance by the kidneys

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5
Q

Uraemia

A

The clinical syndrome that the progressive azotameia displays (failing kimdeys)

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6
Q

Breathlessness in CKD

A

Anaemia
Fluid overload (pulmonary oedema)
Metabolic acidosis (lost bicarbonate)
Associated heart failure

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7
Q

Kaussmal respiration

A

Fast, deep respiration (blowing off extra CO2- compensate for the increased acid that the ketones have produced)

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8
Q

Indications for acute dialysis

A

AEIOU

Acidosis, Electrolytes (refractory hyperkalaemia), Ingestion of toxins, Overload (fluid), Uraemia

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9
Q

CKD Definition

A

Kidney damage (marker of kidney damage eg.proteinuria) or a reduction in the glomerular filtration rate to <60 for more than 3 months duration (first 2 stages have to have kidney damage, the next 3 just need eGFR below 60)

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10
Q

CKD Sx

A

Asymptomatic usually

Fatigue, oedema, SOB (oedema, anaemia, metabolic acidosis), nausea, vomiting, pruritis, anorexia, hyperkalaemia, hyperphosphataemia, hypocalcaemia, metabolic acidosis, CKD MBD

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11
Q

Investigations for CKD

A

Urinalysis- abnormal urine sediment, haematuria, light chains, protein quantification (albumin:creatinine (ACR))
Bloods- UE (hyperkalaemia, hyperphosphatemia, hypocalcaemia, creatinine, eGFR), PTH, FBC (anaemia)
USS- shrunken kidneys with fibrotic parenchyma
Renal biopsy determine underlying cause

NB- 2 tests required 3 months apart to confirm a diagnosis

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12
Q

Management of CKD

A

Refer to nephrology if they meet criteria
Optimise diabetic control
Lifestyle advice- dietary advice, exercise, smoking, weight, vaccines, nephrotoxic drug avoidance (NSAID, vancomycin), counselling
ACE (raised A:Cr), ARB, statin (all CKD pts need statin)- BP 130/80 or 125/75 (proteinuria)
NHP Ca channel blocker
Early education about RRT
Iron and exogenous EPO if anaemia
Remedy secondary hyperparathyroidism (vitamin D analogue, phosphate binding drug)
RRT or transplant

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13
Q

Referral to nephrologist

A

EGFR- less than 30
ACR- above 70
Accelerated progression defines as a decrease in EGFR of 15ml/min or 25% in 1 year
Uncontrolled HTN despite 4 hypertensives

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14
Q

CKD MBD X-ray

A

Rugger jersey appearance of the spine (striped densities)

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15
Q

ACE and kidney function

A

EGFR can fall 25% and creatinine can rise 30%

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16
Q

Indications for long term dialysis

A

End stage renal failure (stage 5 CKD)
Any acute indication continuing long term

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17
Q

Contraindications to a renal transplant

A

Absolute- metastatic cancer
Temporary- active infection, HIV with viral replication, unstable CVD
Relative- CVD, CCF

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18
Q

Sx of diabetic nephropathy

A

Initially asymptomatic, HTN, oedema, foamy urine

NB- retinopathy and neuropathy as well (ask about these)

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19
Q

Investigations for diabetic nephropathy

A

Urine sample for urinalysis (proteinuria), ACR (not detected on a dipstick), glucosuria, finger prick BM
Bloods- FBC (anaemia), UE, blood glucose, HBA1c
Kidney USS- exclude other impairment (large kidneys initially also)
Kidney biopsy- if evidence of another systemic disease (also when no retinopathy- often occur together)

NB- check for retinopathy and neuropathy

NB- ACR should be repeated twice more over 3-6 months to confirm diagnosis

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20
Q

Management of diabetic nephropathy

A

Conservative- optimise blood sugars, BP (130/80), dietary protein restriction
ACE-I (or ARB, even if BP normal)
Statin- control hyperlipidaemia

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21
Q

Pathognomic feature of DN on a microscopy slide

A

Kimmelsteil Wilson lesions

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22
Q

Stages of CKD

A

1- 90+
2- 60+
3a- 45+
3b- 30+
4- 15+
5- below 15

NB- can only diagnose stage 1 and 2 if there is supporting evidence

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23
Q

Management of CKD MBD

A

Low phosphate diet first, then phosphate binders eg. Sevelamer or calcium carbonate
Vitamin D
Parathyroidectomy
Bisphosphonates if at immediate risk of a fracture

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24
Q

ACE-I and CKD

A

Can be used in CKD
May cause drop in eGFR of 25% and a rise in creatinine of 30%
Used when a raised albumin:creatinine ratio

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25
Q

ESRD

A

Stage 5 CKD (eGFR less than 15) requiring RRT

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26
Q

AVF complications

A

Aneurysm
Infection
Thrombosis
Stenosis
STEAL syndrome
High output heart failure
Failure

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27
Q

Steal syndrome

A

Distal ischaemia of the AVF limb

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28
Q

Immunosuppressants post renal transplant

A

Tacrolimus
Mycophenolate
Prednisolone

29
Q

CKD and hypocalcaemia

A

Indicates that CKD is chronic and not acute

30
Q

Water requirements in adult maintenance fluids

A

25-30ml/kg/day (not child)

31
Q

Troublesome gynaecomastia on spironolactone

A

Eplerenone

32
Q

Raised renin

A

Can differentiate primary and secondary hyperaldosteronism
If raised, likely secondary eg. Renal artery stenosis

33
Q

Sevelamer

A

Non calcium based phosphate binder

34
Q

Complication of orang transplantation

A

Squamous cell skin cancer

35
Q

Hyper acute transplant rejection

A

No treatment- remove graft
Caused by pre existing antibodies against ABO or HLA

36
Q

AKI vs CKD

A

CKD- hypocalcaemia and bilateral small kidneys, and blood tests will reveal a chronic picture (ie. 3 months duration)

Exceptions to small kidneys;
-ADPKD
-diabetic nephropathy
-amyloidosis
-HIV associated nephropathy

37
Q

Management of ADPKD

A

Manage complications eg. Anti HTN, avoid NSAIDs, regular monitoring, lifestyle modification (avoid impact sports, fluids, etc.)
Genetic counselling
Tolvaptan (vasopressin receptor antagonist) in some patients
Renal transplant (only cure)

NB- 25% have no FH (recessive is a very rare disease and usually presents in childhood, not adulthood)

38
Q

Alport syndrome

A

Inherited in Xlinked dominant pattern
Abnormal GBM
Features;
Microscopic haematuria
Renal failure
Bilateral deafness
Retinitis
Protruding Lens
Split laminate densa/basket weave appearance (renal biopsy)

NB- if their renal transport fails, it could be due to the presence of anti GBM antibodies

39
Q

Treatment of CKD anaemia

A

Determine iron status first- may require IV iron before erythropoietin stimulating agent
ESA’s = erythropoietin and darbepoetin

40
Q

Calcium based phosphate binders

A

Eg. Calcium carbonate

Problems- hypercalcaemia and vascular calcification

41
Q

Pathophysiology of CKD MBD

A

Low vitamin D
High phosphate
Low calcium
Secondary hyperparathyroidism (due to low calcium)

NB- prolonged secondary hyperparathyroidism can cause tertiary hyperparathyroidism

42
Q

EGFR is based on what variables

A

CAGE

Creatinine
Age
Gender
Ethnicity

NB- pregnancy, muscle mass (amputee, body building), eating red meat 12 hours prior, can all affect result

43
Q

CKD HTN management

A

ACE first line (good for proteinuria)
Furosemide can be added

44
Q

CKD and proteinuria

A

NICE recommend using ACR (albumin:creatinine ratio)
3mg/mmol is clinically important proteinuria

45
Q

Proteinuria and referral to a specialist

A

ACR of 70+ (unless caused by diabetes and properly treated)
ACR of 30+ with persistent haematuria after exclusion of UTI
ACR of 3-29 with persistent haematuria and other risk factors eg. Declining eGFR, CVD

46
Q

Management of CKD proteinuria

A

ACE (or ARB)
If ACR is 70+, give ACE regardless if BP

47
Q

Common causes of polyuria

A

Diuretic use
Caffeine and alcohol
Diabetes Mellitus
Lithium
Heart failure

48
Q

Renal transplant post op problems

A

ATN graft
Vascular thrombosis
Urine leakage
UTI

49
Q

Hyper acute rejection (minutes to hours)

A

Pre existing antibodies to ABO or HLA
Type 2 hypersensitivity
No treatment and remove graft

50
Q

Acute graft failure (<6 months)

A

Cell mediated cytotoxic T cells (mismatch of HLA)
Asymptomatic (rising creatinine, pyuria, proteinuria)
Reversible (steroids and immunosuppressants)

NB- CMV is a cause

51
Q

Chronic graft failure (6 month +)

A

Antibody and cell mediated mechanism
Fibrosis to transplant
Recurrence of original disease

52
Q

Immunosuppression post transplant regime

A

Initial- cyclosporin/tacrolimus + monoclonal antibody
Maintenance- ciclosporin/tacrolimus, + MMF, + sirolimus
Add steroids if acute rejection episodes

53
Q

Cyclosporin

A

Calcineurin inhibitor (T cell inactivation)
HTN, hyperlipidaemia, acute rejection

54
Q

Tacrolimus

A

Impaired glucose tolerance and diabetes

55
Q

MMF

A

B and T cell proliferation
SE- GI and marrow suppression

56
Q

Sirolimus (rapamycin)

A

IL-2 receptor
Hyperlipidaemia

57
Q

Diabetic nephropathy management

A

Optimise glycaemic control
Dietary protein restriction
BP (less than 130/80)
ACE or ARB
Statin for dyslipidaemia

58
Q

Side effects of erythropoietin

A

Accelerated HTN (encephalopathy and seizures)
Bone aches
Flu like symptoms
Skin rashes, urticaria
Pure red cell aplasia
Iron deficiency

59
Q

Falconi syndrome Sx

A

Polyuria
Glucosuria
Phosphaturia
Osteomalacia

60
Q

Causes of Falconi syndrome

A

Cystinosis
Sjogrens
Multiple myeloma
Nephrotic syndrome
Wilson’s disease

61
Q

Fibromuscular dysplasia

A

Renal artery stenosis secondary to atherosclerosis is most common cause of renal VD, but FMD causes the remaining 10%
90% patients are female
HTN, CKD or acute renal failure due to ACE
Flash pulmonary oedema

NB- don’t use ACE or ARB in renal artery stenosis (CCB for HTN)

62
Q

Caution with 0.9% saline

A

Large volumes can cause hyperchloraemic metabolic acidosis

63
Q

Caution with Hartman’s

A

Contains potassium so shouldn’t be used in hyperkalaemia

64
Q

Preferred anticoagulants for patients with renal impairment

A

Apixaban

65
Q

Kidney size on USS

A

Large- HIV nephropathy, autosomal dominant polycystic kidney disease, diabetic nephropathy and amyloidosis.

Small- CKD, Glomerulonephritis, hypertension induced nephropathy, renal artery stenosis, chronic pyelonephritis

66
Q

Vitamin D and CKD

A

Alfacalcidol is used as a vitamin D supplement in end-stage renal disease because it does not require activation in the kidneys

67
Q

Common electrolyte abnormality ESRD

A

This combination of hypocalcaemia and hyperkalaemia is often seen in patients undergoing dialysis.

68
Q

ESRD and pain relief

A

Oxycodone is a safer opioid to use in patients with moderate to end-stage renal failure

Year 3 OSCE (61 decks)

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