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Renal > CKD > Flashcards

CKD Flashcards

1
Q

Five functions of the kidney

A
  1. Waste clearance
  2. Fluid balance
  3. Electrolytes and acid base clearance
  4. Erythropoetin
  5. Vitamin D
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2
Q

Renal failure- things to address every visit

A

Rubbish removal (appetite, weight loss), fluid state, potassium, anaemia, bone

and as needed- primary disease effects, acute comorbid conditions, vascular risk factors, nutrition (catabolic state- need at least 1g/kg protein per day), dialysis access (when get to about 20mL/min), transplantation (if no significant vascular disease, cancer, or infective risk, look at potential live donors- refer to independent nephtologist to avoid conflict of interest.)

Very late in kidney failure may reduce uraemic symptoms by reducing protein intake but otherwise makes no difference to progression of kidney failure and nutrition wise worse off! Protein restriction is out.

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3
Q

How much kidney function needs to be lost before creatinine goes off?

A

50-60%

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4
Q

What level CKD do you start to see anaemia?

A

eGFR under 60 ml/min

Good clue this is CKD not acute

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5
Q

If small kidneys in workup of CKD, when would you not do a biopsy?

A

When less than 8cm span- too scarred to be of use

Do it if norma or enlarged or small but not too small

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6
Q

What is the dialysis paradox?

A

survival disadvantage with lower BP
Survival advantage in obese patients

reverts if transplanted

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7
Q

what does PBS allow in terms of EPO?

A

Hb less than 100 and other causes excluded and eGFR under 60

Target Hb 100-120
Pure red cell aplasia no longer an issue

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8
Q

Early on it was established that end up giving less EPO if the patient is not iron deficient. EPO creates a functional iron deficiency.

Aims for transferrin sats of…
Aiming ferritin of…

A

Tsat-20-50%

Ferritin aim 300-500

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9
Q

Common exam Q: causes of EPO resistance?

A 
Non compliance
Absolute or functional iron deficiency
Chronic blood loss
Infection or inflammation
Other haematinic deficiency
Malignancy
Hyperparathyroidism-->fibroses BM
Malnutrition
Inadequate dialysis
Drugs eg ACEi
Aluminium toxicity
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10
Q

How is EPO given?

A

EPO alpha - weekly to FN subcut or IV
EPO beta- weekly to FN subcut or IV
EPO lambda - IV only and weekly to FN
Darbepoetin aplha subcut or IV weekly to monthly
Methoxy polyethylene glycol epoetin beta (micera)- only one still on patent- subcut or IV monthly- thought of as the only true monthly agent

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11
Q

What is the target PTH in CKD and why?

A

Uraemic bones are less responsive to PTH so aim for 2-4 times the upper limit of normal.
Risk of adynamic bone disease if PTH kept normal

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12
Q

Hyperparathyroidism causes what type of bone pattern

A

Osteitis fibrosa cystica

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13
Q

Adynaic bone disease related to…

A

aluminium in water and aluminium based phosphate binders

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14
Q

Target phosphate in CKD?

A

0.8-1.6 mmol/L

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15
Q

Target Calcium?

A

2.1-2.4 mmol/L

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16
Q

Calcium by phosphate product target?

A

under 4.0

17
Q

Why was cinacalcet taken off the PBS this year?

A

PTH sensitised to respond to lower Ca levels - improves survival surrogates, lowers PTH, lowers calcium, lowers phosphate BUT No survival benefit in EVOLVE trial so delisted august 2015

Causes nausea +++ (not the reason)

18
Q

Approach to renal bone disease?

A
  1. Control phosphate first with phosphate binders eg ca carbonate,
19
Q

Most common cause death on dialysis?

A

Sudden cardiac death (not same as atherosclerotic IHD pathophysiology)
Abnormal myocardial structure, fibrosis

20
Q

Phosphate binders with or without food?

A

WITH! And chewed sometimes (depends type)

usually don’t restrict phosphate diet because risks hypoalbuminaemia

21
Q

Options for reducing phosphate

A

parathyroidectomy does drop phosphate slightly in secondary HPT
Phosphate binders
Extended hours haemodialysis - time dependent thing to remove

22
Q

How does cinacalcet work?

A

Calcimimetic to trick parathyroid into thinking needs to reduce excretion
Treatment for secondary hyperparathyroidism in dialysis patients
Causes GI side effects and hypocalcaemia
Parathyroid goes right down
Phosphate stays same or slight decrease
Has now come off PBS: EVOLVE study 2012 showed RCT - inconclusive effect on CV events and mortality (high cross over from placebo arm)

23
Q

Unwanted side effects of calcitriol

A

Reduces PTH secretion but sadly increases ca and phosphate GI absorption.
Also increases risk of low PTH adynamic bone disease

24
Q

Why is adynamic bone disease feared?

A

low turnover bone disease induced overuse of calcitriol.

increased fracture and CV risks from vascular calcification

25
Q

FGF-23- what is the significance?

A

Possible marker for mortality in dialysis patients

26
Q

How do you approximate what the daily protein excretion is from ACr?

A

eg 640 mg/mmol uACR–>6.4 g/day

27
Q

What are non-minimal change, non membranous causes of nephrotic syndrome?

A 
Amyloidosis
Fibrillary GN
Cryoglobulinaemia
Immunotactic GN
MCGN
FSGS in black people

interstitial nephritis is an unlikely cause of nephrotic syndrome unless coexisting MCD from NSAID

28
Q

Does glycaemic control help in CKD from diabetes?

A

Once impaired GFR or macroalbuminuria, no evidence of real benefit

29
Q

Best ways to assess dialysis efficacy?

A

phosphate- but influenced by phosphate binders
beta2 microglobulin - marker of “middle molecule” clearance- removal enhanced by longer hours of dialysis and haemodiafiltration
Urea reduction ratio- reflects small solute clearance - not pre-dialysis urea.

30
Q

Benefits vs harm of targeting normal Hb in CRF?

A

Benefits reduce red cell transfusions and iron overload and possibly increase QOL
Harm is CV events- stroke, heart failure, access thrombosis, hypertension, worse outcomes in cancer patients, and cost where there is not actually a benefit.

31
Q

What particuarly increases risk of NHL/PTLD?

A

EBV donor positive recipient negative

it’s generally the infection driven cancers eg HSV for cervival nd HHV-8 for kaposi sarcoma rather than hormonally driven cancers in renal transplant

32
Q

What glomerulonephritis is cirrhosis associated with?

A

IgA nephropathy due to reduced clearance of IgA

33
Q

Which is worse for gingival hyperplasia? Tacrolimus or cyclosporine?

A

Cyclosporine

34
Q

Why are mTOR inhibitors avoided post transplant?

A

delayed would healing

35
Q

Which drug is the worst for post transplant diabetes?

A

Tacrolimus

Renal (19 decks)

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