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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
ESRD
Stage 5 CKD (eGFR less than 15) requiring RRT
26
AVF complications
Aneurysm Infection Thrombosis Stenosis STEAL syndrome High output heart failure Failure
27
Steal syndrome
Distal ischaemia of the AVF limb
28
Immunosuppressants post renal transplant
Tacrolimus Mycophenolate Prednisolone
29
CKD and hypocalcaemia
Indicates that CKD is chronic and not acute
30
Water requirements in adult maintenance fluids
25-30ml/kg/day (not child)
31
Troublesome gynaecomastia on spironolactone
Eplerenone
32
Raised renin
Can differentiate primary and secondary hyperaldosteronism If raised, likely secondary eg. Renal artery stenosis
33
Sevelamer
Non calcium based phosphate binder
34
Complication of orang transplantation
Squamous cell skin cancer
35
Hyper acute transplant rejection
No treatment- remove graft Caused by pre existing antibodies against ABO or HLA
36
AKI vs CKD
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
Management of ADPKD
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
Alport syndrome
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
Treatment of CKD anaemia
Determine iron status first- may require IV iron before erythropoietin stimulating agent ESA’s = erythropoietin and darbepoetin
40
Calcium based phosphate binders
Eg. Calcium carbonate Problems- hypercalcaemia and vascular calcification
41
Pathophysiology of CKD MBD
Low vitamin D High phosphate Low calcium Secondary hyperparathyroidism (due to low calcium) NB- prolonged secondary hyperparathyroidism can cause tertiary hyperparathyroidism
42
EGFR is based on what variables
CAGE Creatinine Age Gender Ethnicity NB- pregnancy, muscle mass (amputee, body building), eating red meat 12 hours prior, can all affect result
43
CKD HTN management
ACE first line (good for proteinuria) Furosemide can be added
44
CKD and proteinuria
NICE recommend using ACR (albumin:creatinine ratio) 3mg/mmol is clinically important proteinuria
45
Proteinuria and referral to a specialist
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
Management of CKD proteinuria
ACE (or ARB) If ACR is 70+, give ACE regardless if BP
47
Common causes of polyuria
Diuretic use Caffeine and alcohol Diabetes Mellitus Lithium Heart failure
48
Renal transplant post op problems
ATN graft Vascular thrombosis Urine leakage UTI
49
Hyper acute rejection (minutes to hours)
Pre existing antibodies to ABO or HLA Type 2 hypersensitivity No treatment and remove graft
50
Acute graft failure (<6 months)
Cell mediated cytotoxic T cells (mismatch of HLA) Asymptomatic (rising creatinine, pyuria, proteinuria) Reversible (steroids and immunosuppressants) NB- CMV is a cause
51
Chronic graft failure (6 month +)
Antibody and cell mediated mechanism Fibrosis to transplant Recurrence of original disease
52
Immunosuppression post transplant regime
Initial- cyclosporin/tacrolimus + monoclonal antibody Maintenance- ciclosporin/tacrolimus, + MMF, + sirolimus Add steroids if acute rejection episodes
53
Cyclosporin
Calcineurin inhibitor (T cell inactivation) HTN, hyperlipidaemia, acute rejection
54
Tacrolimus
Impaired glucose tolerance and diabetes
55
MMF
B and T cell proliferation SE- GI and marrow suppression
56
Sirolimus (rapamycin)
IL-2 receptor Hyperlipidaemia
57
Diabetic nephropathy management
Optimise glycaemic control Dietary protein restriction BP (less than 130/80) ACE or ARB Statin for dyslipidaemia
58
Side effects of erythropoietin
Accelerated HTN (encephalopathy and seizures) Bone aches Flu like symptoms Skin rashes, urticaria Pure red cell aplasia Iron deficiency
59
Falconi syndrome Sx
Polyuria Glucosuria Phosphaturia Osteomalacia
60
Causes of Falconi syndrome
Cystinosis Sjogrens Multiple myeloma Nephrotic syndrome Wilson’s disease
61
Fibromuscular dysplasia
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
Caution with 0.9% saline
Large volumes can cause hyperchloraemic metabolic acidosis
63
Caution with Hartman’s
Contains potassium so shouldn’t be used in hyperkalaemia
64
Preferred anticoagulants for patients with renal impairment
Apixaban
65
Kidney size on USS
Large- HIV nephropathy, autosomal dominant polycystic kidney disease, diabetic nephropathy and amyloidosis. Small- CKD, Glomerulonephritis, hypertension induced nephropathy, renal artery stenosis, chronic pyelonephritis
66
Vitamin D and CKD
Alfacalcidol is used as a vitamin D supplement in end-stage renal disease because it does not require activation in the kidneys
67
Common electrolyte abnormality ESRD
This combination of hypocalcaemia and hyperkalaemia is often seen in patients undergoing dialysis.
68
ESRD and pain relief
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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