Chronic Kidney Disease

Question 1

Trial of prednsion

Serologic workup for glomeruloneprhitis, ANCA or antiGBM titers

Perform renal biopsy

Answer 1

Will make DM worse

Look for hematuria…if neprhitic, then yes

Reasonable choice if no past lab values and lack of retinopathy

Question 2

Diabetic neprhopahty biopsy

Answer 2

Nodular glomerulosclerosis

KImmelstiel-Wislon nodules

Question 3

Interventions that delay progression

Answer 3

Proper dx of etiology
Blood sugar control
BP control (angiotensin inhibiton)
Weight and lipid control - can reduce proteinuria

Question 4

Continue lisonopril

Admist for emergent dialysis

Establish Peripheral IV and saline

No changes

Reduce lisonpril

Answer 4

K of 6 is too high to ignore

Only if med therapy failed or pt oliguric

Saline can induce kaliuresis

Reduce lisinopril - will lower the K

Question 5

RBC transfusion

Stop diuretics

Refer for education

Answer 5

IN chronic anemia, only if Hgb under 7

Might not help kidney function if still hypervomeic

Now that clearance under 20 and predictably processing appropriate

Question 6

Gaols of predialysis clinic

Answer 6

PReserve kidney function
PRevent complications

Educate patients about RRT optioins, including withholding dialysis
Arrange appropriate dilaysis access

When EGFR<30

Question 7

Hemodialyhsis

Answer 7

Semipermeable membrane

Diffusion principles

Ultrafiltration achieved by changing the hydrostatic forces across the membrane

Question 8

Adv of HD

Answer 8

More rapid and profound

Incresed pt oversight bc seen more oven

More structure

Question 9

Disadv of HD

Answer 9

More rapid so may be more poorly tolerated

Inc pt time commitment

Question 10

Vascular access

Answer 10

Use in non-dom arm

No clots, nerve issues, etc

Connect artery to vien…begin distally

Mature over 2-3 mos and lasts 2-4 yrs

Clotting infection and nerve sx are coms

Question 11

Peritoneal dialysis

Answer 11

Dialysate placed in periotneal and osmotic gradients used for ultrafiltration

Sugars used to increase osmolality - hyperglycemia and weight gain

Question 12

Adv of PD

Answer 12

Improved preservation of residual fxn

increased pt independenence

Fewer dietary probs

Anticoag unneccsary

Question 13

Disadv of PD

Answer 13

Early survivial benefit depends on pt

Weight gain

Glycemic control comps

Risk of infection

Question 14

Peritoneal access

Answer 14

Place catheter in visible location to see entry

Coils into lower pelvis for access to dialysate

Use within 1-2 weeks

Infections, catheter issues

Question 15

Transplant consideration

Answer 15

Smoking status

Tests to rule out malignancy and test kidney function

Immunosuppresision

3 yr wait time for cadaveric

Living donors do best

Question 16

HD vs PD mortality

Answer 16

PD better for first 1-2 yrs

HD better after

Question 17

When is RRT NOT the right choice?

Answer 17

Nusing home or cannot eat indentity

Vegetative state?

Question 18

Rationing of dialysis tx

Answer 18

Expected to survive for only a few mos should not be offered dialysis

Avoid suffering

Poor quality of life preidcotr of mortaity

Question 19

Objective criteria

Answer 19

Poorer - age, male, serum albumin, malnutrition, impaired function, diabetes, coronary heart dz

Time limited trial may be useful

Question 20

SPIRES

Answer 20

Setup
Perception
INvitation
Recommendations
Empathize
Summarize

Question 21

Principles of palliative in ESRD

Answer 21

Assess QOL
Advance directives
Sx control
Bereavement care

Question 22

Central venous catheter comps

Answer 22

Infection or central venous occlussion