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A. MLA Map Paediatrics > Chronic Kidney Disease > Flashcards

Chronic Kidney Disease Flashcards

1
Q

Chronic kidney disease (CKD) is a chronic reduction in kidney function sustained over three months. It tends to be permanent and progressive. What is the incidence of CKD?

1 - 1 cases per 100,000
2 - 10 cases per 100,000
3 - 100 cases per 100,000
4 - 1000 cases per 100,000

A

3 - 100 cases per 100,000

Equally likely in men and women

To be diagnosed with CKD, decline in renal function must persist for >12 weeks

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2
Q

Chronic kidney disease (CKD) is a chronic reduction in kidney function sustained over three months. It tends to be permanent and progressive. What age does the the incidence of CKD peak?

1 - 30-40
2 - 50-60
3 - 60-70
4 - >75

A

3 - 60-70

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3
Q

The function of the kidneys declines with age, but which of the following can accelerate the decline in renal function?

1 - Diabetes
2 - Hypertension
3 - Medications (e.g., NSAIDs or lithium)
4 - Glomerulonephritis
5 - Polycystic kidney disease
6 - all of the above

A

6 - all of the above

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4
Q

Which patients are at risk of developing CKD?

1 - Diabetes
2 - Hypertension
3 - AKI
4 - CVD
5 - sarcoidosis, vasculitis, SLE,
6 - Family history
7 - all of the above

A

7 - all of the above

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5
Q

All of the following can accelerate the decline in renal function in CKD, but which 2 are most common?

1 - Diabetes
2 - Hypertension
3 - Medications (e.g., NSAIDs or lithium)
4 - Glomerulonephritis
5 - Polycystic kidney disease
6 - all of the above

A

1 - Diabetes
Specifically diabetes nephropathy and causes scarring called golmerula sclerosis

2 - Hypertension
Specifically causes scarring of small vessels of the glomerulus and tubules called nephrosclerosis

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6
Q

In CKD patients can experience:

  • loss of appetite
  • nausea
  • vomiting
  • encephalopathy
  • headaches
  • blurred vision
  • pericarditis

What is the primary cause for all of these symptoms in CKD?

1 - dehydration
2 - uraemia
3 - anaemia
4 - hyponatraemia

A

2 - uraemia
- essentially build up of toxins in the blood of urea
- ammonia produced from amino acid metabolism can also be high and cause these symptoms
- increased urea levels is an indication for dialysis
- ammonia is converted to urea in kidney

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7
Q

What is the primary reason for anaemia in CKD?

1 - haematuria
2 - insufficient anti- coagulant proteins causing bleeding
3 - high levels of erythropoietin
4 - low levels of erythropoietin

A

4 - low levels of erythropoietin
- erythropoietin stimulates bone marrow to make more RBCs

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8
Q

In CKD which of the following is most common?

1 - microcytic anaemia (<80fl)
2 - normcytic anaemia (80-100fl)
3 - macrocytic anaemia (>100fl)
4 - mixture of all of them

A

2 - normcytic anaemia (80-100fl)
- the production is normal, BUT there is less of the RBCs

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9
Q

There are a myriad of complications caused by CKD. Which one of these occurs?

1 - hypercalcaemia
2 - hyperkalaemia
3 - hypernatraemia
4 - hyperphosphatemia

A

2 - hyperkalaemia
- can cause cardiac arrhythmias
- ECH changes tall peaked T waves, increased PR interval, small/absent P wave and widened QRS complex

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10
Q

CKD can cause which 2 of the following that can lead to weak and brittle bones?

1 - unable to activate vitamin D
2 - does not re-absorbs enough Ca2+
3 - uraemia inhibits PTH release
4 - all of the above

A

1 - unable to activate vitamin D
2 - does not re-absorbs enough Ca2+

PTH is released to initiate Ca2+ release from bones causing secondary hyperparathyroidism
- over time this causes renal osteodystrophy and Osteomalacia

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11
Q

In CKD, all of the following can occur, EXCEPT which one?

1 - low serum phosphate
2 - low vitamin D activity
3 - low serum calcium

A

1 - low serum phosphate
Causes high phosphate as the kidneys are unable to excrete it

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12
Q

Why can CKD result in hyperventilation?

1 - low HCO3-
2 - hyperkalaemia
3 - metabolic acidosis
4 - all of the above

A

4 - all of the above
- hyperkalaemia causes metabolic acidosis
- HCO3- is insufficient to compensate
- lungs remove CO2 in an attempt to reduce pH, causing hypocapnia

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13
Q

Which of the following drugs is NOT associated with causing CKD?

1 - PPIs
2 - anti-depressants
3 - NSAIDs
4 - Lithium

A

2 - anti-depressants

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14
Q

CKD is when there is an abnormality in kidney structure and function for >3 months that has implications of affecting a patients health. Which 2 of the following are used in determining the stage of CKD?

1 - creatinine
2 - eGFR
3 - albumin
4 - glucose

A

2 - eGFR
3 - albumin
- in urine its called albuminuria

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15
Q

CKD is when there is an abnormality in kidney structure and function for >3 months that has implications of affecting a patients health. eGFR and albumin are used to stage CKD. Based on the patients eGFR, CKD can be staged between G1-G5. What is the definition of stage G1?

1 - 15-29
2 - >90
3 - <15
4 - 60-89
5 - 45-59
6 - 30-44

A

2 - >90
- normal or high eGFR

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16
Q

CKD is when there is an abnormality in kidney structure and function for >3 months that has implications of affecting a patients health. eGFR and albumin are used to stage CKD. Albuminuria can be used to stage the severity of CKD between A1-A3. What is the albumin cutoff for stage A1?

1 - 30-330mg/g/24h (3-30mg/mmol)
2 - <30mg/g/24 (<3mg/mmol)
3 - >300mg/g/24h (>30mg/mmol)

A

2 - <30mg/g/24 (<3mg/mmol)
- normal to mildly increased

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17
Q

In addition to measuring albumin over 24h, we can also look at what other marker of kidney damage?

1 - blood
2 - glucose
3 - creatine
4 - creatinine

A

4 - creatinine
- easier than measuring albumin alone
- requires just a snapshot

Below are albumin:creatinine ratios:
A1 = <3
A2 = 3-30
A3 = >30

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18
Q

Renal function declines with age, but what is the most common cause that accelerates renal function decline, causing CKD?

1 - hypertension
2 - diabetes
3 - glomerulonephritis
4 - other causes
5 - idiopathic

A

2 - diabetes
- both type 1 and 2 diabetes can cause this

  • glomerulonephritis = essentially nephritic syndrome
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19
Q

Hperglycaemia can lead to glucose binding with proteins and molecules in the blood. What is this process called?

1 - enzymatic glycation
2 - non-enzymatic glycation
3 - glycoselation
4 - glucosurinaemia

A

2 - non-enzymatic glycation
- leads to binding with proteins and lipids in the blood, endothelium and other tissues throughout the body

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20
Q

Hypertension can cause CKD. Which of the following is NOT an affect that leads to CKD in patients with hypertension?

1 - renal arteries dilate
2 - glomerular ischaemia
3 - macrophages and foam cells enter glomerulus and secrete TGF-B1
4 - TGF-B1 induces mesangial cell regression to mesoangioblasts
5 - mesoangioblasts secrete ECM causing glomerular sclerosis (scarring)
6 - glomerular sclerosis reduces ability of glomerulus to filter

A

1 - renal arteries dilate
- renal arteries become stiff and thicken, reducing renal blood flow

  • macrophages and foam cells are common in atherosclerosis, common cause of high BP
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21
Q

Which of the following is the most commonly inherited cause of CKD?

1 - Alport syndrome
2 - Polycystic kidney disease
3 - Gitelman syndrome
4 - Good Pasteurs Syndrome

A

2 - Polycystic kidney disease
- autosomal dominant (non-sex chromosome)
- kidneys become filled with 100s of fluid filled sacs

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22
Q

Polycystic kidney disease (PKD) is the most commonly inherited cause of CKD and causes 100s of fluid filled cysts to form in BOTH kidneys. What is the most common mutation that causes PKD?

1 - PKD 1
2 - PKD 2
3 - PKHD1
4 - P53

A

1 - PKD 1

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23
Q

Polycystic kidney disease is the most commonly inherited cause of CKD and causes 100s of fluid filled cysts to form in BOTH kidneys. How can this leak to CKD?

1 - obstruct collecting system, causing urinary stasis and renal calculi
2 - occlude blood flow causing ischemia
3 - impairs nephrons ability to filter
4 - activates RAAS, which can further damage the kidneys
5 - all of the above

A

5 - all of the above
- kidneys become enlarged

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24
Q

Polycystic kidney disease is the most commonly inherited cause of CKD and causes 100s of fluid filled cysts to form in BOTH kidneys. Which 2 of the following are common symptoms that are present in patients with polycystic kidney disease?

1 - nausea and vomiting
2 - weight loss
3 - flank pain
4 - haematuria

A

3 - flank pain
4 - haematuria

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25
Q

Polycystic kidney disease is the most commonly inherited cause of CKD and causes 100s of fluid filled cysts to form in BOTH kidneys. In addition to have a significant effect on the kidneys, cysts can form in other organs. Which of the following do these typically NOT occur?

1 - liver
2 - seminal vesicles
3 - lungs
4 - vasculature (cause aneurysms in circle of willis or aortic arch)
5 - pancreas
6 - GIT

A

3 - lungs

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26
Q

Alport syndrome is the 2nd most common cause of inherited CKD. This is due to a mutation that causes an abnormal structure and function of a specific type of collagen. Which collagen is typically affected?

1 - type I
2 - type II
3 - type III
4 - type IV

A

4 - type IV

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27
Q

Alport syndrome is the 2nd most common cause of inherited CKD. This is due to a mutation that causes an abnormal structure and function of type IV collagen. All of the following are specifically affected in Alport syndrome due to the high collagen IV content, EXCEPT which one?

1 - lungs
2 - glomerulus
3 - cochlea
4 - eyes

A

1 - lungs
- type IV collagen can be found in all basement membranes though

28
Q

In Alport syndrome there is dysfunctional type IV collagen present in the glomerulus. Does this lead to thickening or thinning of the glomerulus basement membrane?

A
  • becomes thin and porous
  • BUT eventually becomes sclerotic and stiff
  • eventually leads to renal insufficiency or failure
29
Q

In Alport syndrome there is dysfunctional type IV collagen present in the glomerulus leading to a think and porous glomerulus basement membrane. Typically what can be seen in the urine?

1 - proteinuria
2 - microscopic haematuria
3 - gross haematuria
4 - all of the above

A

4 - all of the above
- eventually leads to renal insufficiency or failure

30
Q

Is Alport’s syndrome classes as nephritic or nephrotic?

A
  • nephritic
  • causes glomerularnephritis
31
Q

Which of the following does NOT form part of the triad of Alport’s syndrome?

1 - glomerularnephritis and CKD
2 - complete deafness
3 - sensorineural deafness
4 - retinopathy/lens dislocation

A

2 - complete deafness

  • sensorineural = problem in the inner ear, in Alport’s its a problem with the cochlear
32
Q

Sarcoidosis is an inflammatory disease in which the immune system overreacts, causing clusters of inflamed tissue called “granulomas” to form in different organs of the body. In the kidneys this causes renal sarcoidosis. Which of the following can this cause in the kidneys?

1 - renal calculi
2 - nephrocalcinosis
3 - interstitial nephritis
4 - all of the above

A

4 - all of the above

33
Q

CKD, there is also the risk of accelerated progression, defined as an eGFR of >25% of baseline or a sustained decrease in eGFR of >15mls/min/1.73m2 over 12months. Which of the following are risk factors for developing accelerated progression of kidney disease?

1 - CVD/Hypertension
2 - Proteinuria
3 - AKI
4 - Diabetes
5 - Smoking
6 - African, African-Caribbean or Asian family origin
7 - Chronic use of NSAIDs
8 - Untreated urinary outflow tract obstruction
9 - all of the above

A

9 - all of the above

34
Q

Based on NICE guidelines, what would the eGFR have to be before you refer a patient to a specialist?

1 - eGFR < 30
2 - eGFR < 50
3 - eGFR < 70
4 - eGFR < 90

A

1 - eGFR < 30

35
Q

Based on NICE guidelines, what would the albumin:creatinine ratio (ACR) have to be before you refer a patient to a specialist?

1 - ACR >30mg/mmol
2 - ACR >50mg/mmol
3 - ACR >70mg/mmol
4 - ACR >90mg/mmol

A

3 - ACR >70mg/mmol

36
Q

If a patient is hypertensive, they may need to be referred to see a specialist. How many anti-hypertensives should patients have tried before referral to a specialist?

1 - >2
2 - >3
3 - >4
4 - >6

A

3 - >4

37
Q

If a patient with CKD has a ACR >70mg/mmol, which of the following is 1st line for the management of their BP which is a target of <130/90?

1 - ARB or ACE inhibitor
2 - Calcium channel blocker
3 - Thiazide-like
4 - Potassium-sparing

A

1 - ARB or ACE inhibitor
DO NOT START IF K+ >5, REPEAT BLOOD TEST AND START WHEN <5

ACR <70mg/mmol 1st line is Ca2+ channel blocker, except in:
- diabetic
- >55
- afric-carribean

38
Q

What is the first line imaging modality to assess a patient with suspected CKD?

1 - MRI
2 - CT
3 - X-ray
4 - Ultrasound

A

4 - Ultrasound
- used to investigate patients with accelerated CKD, haematuria, family history of polycystic kidney disease or evidence of obstruction.

  • X-ray may also be useful in renal osteodystrophy
39
Q

Based on NICE guidelines, what would the albumin:creatinine ratio (ACR) have to be before you refer them to a specialist?

1 - eGFR < 30
2 - eGFR < 50
3 - eGFR < 70
4 - eGFR < 90

A

3 - eGFR < 70

40
Q

In patients with CKD, which of the following is NOT an aim of management in patients with CKD?

1 - Slow the progression of the disease
2 - Reverse the damage causing CKD
3 - Reduce the risk of CVD
4 - Reduce the risk of complications
5 - Treating complications

A

2 - Reverse the damage causing CKD
- CKD cannot be reversed

41
Q

One of the key aims of managing patients with CKD is to slow the progression of CKD. Which of the following is NOT an approach that can achieve this aim?

1 - Optimise NSAIDs where required
2 - Optimise diabetic control
3 - Optimise hypertensive control
4 - Treat glomerulonephritis

A

1 - Optimise NSAIDs where required

  • essentially we are trying to target modifiable risk factors
  • NSAIDs should be stopped altogether
42
Q

Which 2 of the following can be used to treat anaemia in patients with CKD?

1 - blood transfusion
2 - iron supplements
3 - increased vegetables in diet
4 - erythropoietin infusion

A

2 - iron supplements
4 - erythropoietin infusion

43
Q

Which 2 of the following supplements should be given to treat patients with CKD?

1 - coagulation proteins
2 - vitamin D
3 - HCO3-
4 - Na+ and Cl-

A

2 - vitamin D
- treat renal osteodystrophy

3 -HCO3-
- treat metabolic acidosis

44
Q

Which 2 of the following should be considered in patients with end stage renal disease?

1 - Haemo/peritoneal dialysis
2 - Renal transplant
3 - Blood transfusion
4 - all of the above

A

1 - Haemo/peritoneal dialysis
2 - Renal transplant

45
Q

What is the 1st line medication in patients with CKD?

1 - statins
2 - ACE-I
3 - B-blockers
4 - calcitonin

A

2 - ACE-I
- must monitor K+ as ACE-I can cause hyperkalaemia

In AKI drugs including ACE-I would typically be stopped, but good in CKD

46
Q

What is the target for BP in patients with CKD and a ACR >70mg/mmol?

1 - <160/90
2 - <140/90
3 - <130/80
4 - <120/80

A

3 - <130/80

<140/90 in CKD with ACR <70mg/mmol?

Drugs used in CKD to slow the disease progression:
- ACE inhibitors (or angiotensin II receptor blockers)
- SGLT-2 inhibitors (specifically dapagliflozin)

47
Q

Which of the following medications can be used in CKD to slow the progression of CKD?

1 - Gliclazide
2 - Metformin
3 - Dapagliflozin
4 - Dulaglutide
5 - Linagliptin

A

3 - Dapagliflozin

SGLT-2 inhibitor

Does increase risk of:
- DKA in diabetes
- UTI

NOT used in PVD due to risk of Fourniers gangrene

48
Q

When measuring protein in the urine, which of the following is more effective?

  • albumin:creatinine ratio (ACR)
  • protein:creatinine ratio (PCR)
A
  • albumin:creatinine ratio (ACR)
49
Q

Sarcoidosis is an inflammatory disease in which the immune system overreacts, causing clusters of inflamed tissue called “granulomas” to form in different organs of the body. In the kidneys this causes renal sarcoidosis. Which of the following can this cause in the kidneys?

1 - renal calculi
2 - nephrocalcinosis
3 - interstitial nephritis
4 - all of the above

A

4 - all of the above

  • nephrocalcinosis = Ca2+ that builds up in the nephrons
  • 5% of patients with sarcoidosis develop renal sarcoidosis
50
Q

Acute/chronic cardiac function can lead to AKI/CKD and AKI/CKD can lead to acute/chronic heart problems, which is called cardio-renal syndrome. Cardio-renal syndrome (CRS) can be divided based on the cause. Which of the following matches CRS type I?

1 - chronic heart failure causing prolonged kidney damage and CKD
2 - Co-development of HF and CKD
3 - CKD causing CHF
4 - AKI causing acute cardiac abnormalities (arrhythmias, HF)
5 - Acute decompensated heart failure causing AKI

A

5 - Acute decompensated heart failure causing AKI

Types 2-5 can be seen in the image

51
Q

Treating patients with cardio-renal syndrome can be difficult. What should the primary aim of treating patients with CRS be?

1 - reduce eGFR
2 - reduce cardiac workload
3 - offload fluid
4 - increase cardiac output

A

3 - offload fluid
- larger than usual dose of diuretics may be required

52
Q

Treating patients with cardio-renal syndrome can be difficult. in patients with CHF, which of the following is often resistant to diuretics?

1 - hyponatraemia
2 - hypernatraemia
3 - hypercalcaemia
4 - hypocalcaemia

A

1 - hyponatraemia

  • if diuretic resistant dialysis or filtration may be used
53
Q

Treating patients with cardio-renal syndrome can be difficult. The kidneys are especially sensitive to nephrotoxic drugs. Which of the following is NOT nephrotoxic?

1 - NSAID
2 - ACE inhibitors
3 - diuretics
4 - aminoglycosides (Gentamicin)

A

3 - diuretics

  • ACE inhibitors are great for cardiac function, but can be bad for the kidneys
  • ACE inhibitors can also cause hyperkalaemia, which can be made worse with CKD that cannot filter out K+
54
Q

In a patient with liver cirrhosis there is a reduced effective blood volume. What can this lead to an increase in?

1 - increased aldosterone
2 - decreased RAAS activation
3 - decreased ADH
4 - increased TSH

A

1 - increased aldosterone
- reduced effective blood volume causes hypotension and activation of the RAAS
- RAAS system stimulates the release of aldosterone

55
Q

In a patient with liver cirrhosis there is a reduced effective blood volume, which leads to increased activation of RAAS and aldosterone levels. What electrolyte is often increased in liver cirrhosis?

1 - K+
2 - Na+
3 - Mg2+
4 - Ca2+

A

2 - Na+
- made worse if you have a salty meal
- patients often do not respond to diuretics

MUST REDUCE SALT INTAKE IF SALT INTAKE EXCEEDS NA+ EXCRETION AS INCREASES WATER RETENTION

56
Q

In patients hospitalised with liver cirrhosis, AKI is much more likely. Of those with an AKI, what is the most common cause of CKD?

1 - pre-renal
2 - intra-renal
3 - post-renal
4 - all equally affected

A

1 - pre-renal

Due to hypovolaemia and hypoperfusion of the kidneys

57
Q

In patients hospitalised with liver cirrhosis, AKI is much more likely. Of those with an AKI, the most likely cause of CKD was pre-renal pathology. This can be divided into fluid responsive and fluid unresponsive. Of the the fluid responsive patients, which of the following is a likely cause of the CKD?

1 - infection
2 - vasodilators
3 - hypovolaemia
4 - all of the above

A

4 - all of the above

58
Q

In patients hospitalised with liver cirrhosis, AKI is much more likely. Of those with an AKI, the most likely cause of CKD was pre-renal pathology. This can be divided into fluid responsive and fluid unresponsive. Of the the fluid responders patients, which of the following is a likely cause of the AKI?

1 - CHF
2 - hepato-renal syndrome
3 - encephalopathy
4 - pulmonary oedema

A

2 - hepato-renal syndrome

59
Q

Patients with hepato-renal syndrome typically have which of the following?

1 - portal hypertension
2 - severe alcoholic hepatitis
3 - alcoholic liver cirrhosis
4 - metastatic tumour
5 - all of the above

A

5 - all of the above

  • as liver function declines so to does perfusion of the kidneys, leading to AKI and eventually CKD
60
Q

Does hepato-renal syndrome have a good or bad prognosis?

A
  • bad prognosis
61
Q

There are 2 types of hepato-renal syndrome (HRS). Which of the following is type 1 and type 2 HRS?

1 - Diuretic resistant ascites: Less rapid deterioration in renal function; associated with refractory ascites and poor survival (months)

2 - HRS-AKI: Oliguric, doubling of serum creatinine within 2 weeks; outcome is poor (days to weeks) with a precipitating insult

A

1 - Diuretic resistant ascites: Less rapid deterioration in renal function; associated with refractory ascites and poor survival (months)
= TYPE 2

2 - HRS-AKI: severe and rapid decline, oliguric, doubling of serum creatinine within 2 weeks; outcome is poor (days to weeks) with a precipitating insult (i.e. infection) and often need recurrent paracentesis
= TYPE 1

62
Q

In hepato-renal syndrome, does type 1 or type 2 have a better mortality rate?

A
  • type 2
  • type 1 = 2 weeks
  • type 2 = 4-6 months
63
Q

In hepato-renal syndrome, why is creatinine often a bad marker?

1 - patients levels become too high to measure
2 - slow to respond to changes
3 - patients are cachexic, malnourished and liver disease)
4 - creatinine does not reach the kidneys

A

3 - patients are cachexic, malnourished and liver disease)

  • they don’t have the levels of creatinine to rise, but kidney damage is present
64
Q

The prognosis in hepato-renal syndrome (HRS) is poor and treatment is often supportive in nature. Which of the following is NOT an aspect of treatment in HRS?

1 - Na+ and H20 restriction
2 - albumin supplements
3 - treat tigger of HRS
4 - terlipressin

A
65
Q

Terlipressin, which is a vasopressin analogue can be used in patients with hepato-renal syndrome (HRS). Where does Terlipressin have its main effects?

1 - blood flow to kidneys
2 - increased preload to heart and increase blood flow to the kidneys
3 - reduces afterload in patients
4 - vasoconstricts the splanchnic circulation

A

4 - vasoconstricts the splanchnic circulation

  • Terlipressin = vasoconstrictor
  • increased vasoconstriction of the splanchnic circulation will aim to increase perfusion of the kidneys
66
Q

Terlipressin, which is a vasopressin analogue can be used in patients with hepato-renal syndrome (HRS). Which 2 of the following can be performed in one of the specialist liver units if available?

1 - Transjugular intrahepatic portosystemic shunt (TIPS)
2 - Transplantation
3 - Dialysis
4 - all of the above

A

4 - all of the above

  • TIPS = removes fluid from portovenous system and redivert blood flow to the kidneys
  • dialysis = not great, prolongs suffering and not great treatment
  • lung transplantation is often not suitable either

A. MLA Map Paediatrics (61 decks)

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