Chronic kidney disease and renal replacement Flashcards
Calfific uremic arteriolopathy/ understand the stages of lesions
-begins as red, tender, broad violaceous lesion with subcutanous nodules> clean based ulcer> finally covered by black eschar ( this is what I have seen mostly)
Hypophosphatemia with iv iron?
- Ferric carboxymaltose ( Injectafer)
- normocalcemic primary renal PO4 wasting
- increased FGF23 and low 1,25 OH2 viatamin D, normal 25 OH vitamin D
- severe enough that people have gotten fractures
What is Na sieving and what is the clinical significance?
- '’Na left behind’’ in plasma while water goes into dialysate
- consequence: hypernatremia and increased thirst
- hence, longer dwell to avoid Na sieving
When would you consider plasma exchange as treatment modality in drug toxicity/ poisoning?
- independent of toxin’s size, charge or protein binding unlike hemodialysis
- especially protein bound
a) Organophosphate poisoning, replace with plasma> cholinesterase
b) Amanita mushroom ( category II indication)
c) Digoxin
d) Snake envenomation
e) Cisplatin
f) Natalizumab used for MS
Methanol toxicity unique findings
- hyperemic optic discs> pupils can be dilated and poorly responsive
- swelling of putamen on CT
- Hemodialysis without anticoagulation due to high risk of hemorrhage in basal ganglia
Can you use Acetazolamide to alkalinize urine in Salicylate toxicity?
-No because it will cause systemic acidosis which will increase CNS toxicity
Know:
1) Bath Salts/ Synthetic cathionine: Cheap alternative for cocaine. Available to purchase from online. Increases sympathetic activity and multiorgan failure.
2) Synthetic cannabinoids can cause AKI, ATN.
-understand role of HD in these toxicities
What are the scenarios when you would do genotype testing in ADPDK?
- potential kidney donors from affected family members with cyst numbers below diagnostic threshold
- young individuals <25 in whom no cysts are detected in US, CT and MRI and family disease is mild.
What is the best predictor of progression to ESRD in ADPKD patients?
-total kidney volume and its changes over the time
NOT age at which patient’s relatives developed ESRD
I think KSAP said: truncating mutation
Treatment of angiomyolipoma
- <3 cm: nothing
- > 3cm growing: mTOR inhibitors
- hemorrhagic complications: embolization+ steroids
Life time risk of RCC in VHL syndrome
> 70% chances of having RCC
So only partial or total nephrectomy can prevent this.
What are the 2 randomized trials which looked into HD clearance? Conclusions? And one other trial you should know?
1)National Cooperative Dialysis study
Kt/V: <0.8 is bad, >1 is good, if you go very high you don’t get much
2) HEMO trial: compared Kt/V 1.3 and 1.7, so no difference. Women might benefit with higher Kt/V than 1.2, as you know V is small
3) Frequent HD Network trial NEJM 2010: Frequent HD vs conventional HD, Frequent with better cardiovascular surrogate outcome LV mass index, BP control, phosphorus control. Adverse effects of interventions need for access
What are the 2 studies in relation to clearance in PD?
- CANUSA and ADEMEX
- Hong Kong PD trial
Patient with CKD stage IV, breast cancer on chemotherapy with intent to curative treatment, anemia management?
- no ESA, treat anemia with periodic tranfusion
- Cancer on active treatment with plan to cure, KDIGO advise against ESA
Factors affecting Cystatin level
-Thyroid hormone, smoking, glucocorticoids
