Chronic renal failure

Question 1

The leading cause of ESRF in Australia is?

Answer 1

Diabetic Nephropathy

GN
HTN
Misc
PCKD

Question 2

Which glomerulopathy is the leading cause of need for RRT in Australia?

Answer 2

IgA Nephropathy

Question 3

Stages of CKD:

Answer 3

1. Damage without loss of GFR
2. Damage with GFR 60-89
3. Moderate decrease in GFR 30-59
4. Severe decrease in GFR 15-29
5. Kidney failure <15 OR on dialysis

Stage 3 is most common

Question 4

Which risk factor best predicts development of renal failure?

Answer 4

Presence of impaired GFR

DM
Age
HTN
Smoking
Obesity

Question 5

In patients with renal disease what is the best predictor of developing ESKD?

Answer 5

Proteinuria

Causes damage to the glomerulus via:

• Hyperfiltration
• Tubular toxicity
• Increased tubular work
• Mesangial toxicity

Therefore proteinuria begets proteinuria –> worsening damage

Question 6

Best screening test for diabetic nephropathy?

Answer 6

Spot urine albumin or protein to creatinine ratio

Question 7

Why treat proteinuria?

Answer 7

Reduction in proteinuria correlates with reduced risk of need for RRT

Question 8

How to treat Proteinuria?

Answer 8

ACE-Is or ARBs

not combination ACE-Is and ARBs–> increased renal impairment

Aldosterone antagonists may reduce proteinuria but use restricted by hyperkalaemia

Treat blood pressure until BP <125/75 if renal disease present or 135/85 if diabetic

Salt restriction

Question 9

What other treat for Diabetes can reduce rates of diabetic nephropathy?

Answer 9

Tight BSL control

Delays CKD progression for T1DM and T2DM

Question 10

What about Bicarbonate therapy?

Answer 10

Appears to reduce progression to ESRF in patients with stage 4 CKD with metabolic acidoisis

Question 11

Indications for urgent dialysis?

Answer 11

Fluid overload
Hyperkalaemia
Uraemia –> pericarditis, pleuritis, encephalopathy, bleeding

?Medication overdose
? Urea >60

Question 12

Haemodialysis pros?

Answer 12

Efficient solute removal
Reasonable fluid removal

Can be done at home overnight
Intermittent

Question 13

Haemodialysis cons?

Answer 13

Intermittent –> large fluctuations in solute and fluid removal and thus BP

Requires good cardiac function

Access can be difficult
Heparin exposure
Exposure of blood to artificial circuit
Need strict attention to fluid and solute intake

Question 14

Peritoneal dialysis pros

Answer 14

2 different types - continuous ambulatory or nocturnal

Continuous –> less fluctuations in fluid and solute control

Cardiac friendly
No heparin or blood contact with artificial products
Allows independance

Question 15

Peritoneal dialysis cons

Answer 15

Requires tenckhoff catheter
Peritonitis and exit site infections

Inefficient - requires residual renal function

Can’t use if previous abdominal surgery or if lung problems

Requires dexterity and vision

Question 16

PD peritonitis microbiology

Answer 16

50% gram positives only

• -> skin contamination
• -> poor technique

15% gram negative only
20% culture negative

4% Polymicromicrobial

• -> multiple gram negatvie or gram negatives and gram positives
• -> LAPAROTOMY/REMOVE CATHETER

<2% Fungal

• -> REMOVE CATHETER
• -> High mortality

Question 17

PD peritionitis antibiotics

Answer 17

Interperitoneal Antibiotics:

• Gram positive and negative cover
• 1st and 4th gen cephlosporins

Fungal:

• Usually prior peritionitis and antibiotics
• Remove catheter

Multiple organisms:
- If enteric – laparotomy

Recurrent PD peritionitis –> sclerosing peritonitis –> crushed bowel —> death

Question 18

In regards to haemodialysis patients survival is improved by?

Answer 18

Increased dialysis duration

Question 19

For a new patient commencing dialysis the most likely cause of death will be:

Answer 19

Cardiovascular event

Risk of CV events is 20-1000x normal in ESRD

Question 20

Use of lipids to reduce CV risk?

Answer 20

Pre-dialysis = improvement
Dialysis patients = nil effect

CV disease on dialysis ? calcific disease

Question 21

What about treating BP to reduce CV risk?

Answer 21

BP targets on dialysis are unclear ?140/90

Treat is useful to reduce LVH

Should be possible in 90% of patients through fluid removal alone
If treatment need Beta blockers are the best agent

Question 22

Haemaglobin target in ESRF patients?

Answer 22

Aim 110-130

Increased mortality >130
Fluctuations also associated with increased mortality

Question 23

? Iron replacement?

Answer 23

Due to chronic inflammatory state in ESRF –> reduced ability to store and access iron

Aim:

• Target ferritin >200
• Transferrin saturation >20%

Give IV iron

Question 24

Which markers in renal bone disease signal increased risk of death?

Answer 24

Serum Phosphate and Calcium

PTH levels have nil association with mortality

?secondary to calcification of vessels - associated with CV death

Question 25

Treatment of hyperphosphataemia?

Answer 25

Reduce PO4 in blood:

• Dialysis
• GIT binders:
  
  • -> Caltrate - avoid if HyperCa
  • -> Magnesium
  • -> Aluminum
  • -> Non Ca based

Prevent HyperPTH

• -> stops bone resorption of PO4
• Replace Vitamin D to maintain normal Ca levels
• If non responsive –> PTHectomy

Question 26

What is the cause of renal bone disease?

Answer 26

Osteomalacia from hyperparathyroidism +
Osteopenia from low Vitamin D

Not OP

Question 27

What is calciphylaxis?

Answer 27

Subepidermal calcific obstruction of small vessels
–> causes necrotic ulceration or the skin or internal organs

Can be triggered by hypotension

Central type >50% mortality

Treatment: Hyperbaric O2 and calcium and phosphate reduction

Question 28

Which biomarker is the strongest predictor of death?

Answer 28

Albumin

IL-6 >CRP for prediction of CV mortality

Question 29

Which equation is used for dosing of drugs in patients with renal dysfunction?

Answer 29

Cockroft Gault