CKD, AKI, Transplantation

Question 1

Low GFR < 60 ml/ min for 70 days, CKD or AKI?

Answer 1

• Defined as GFR of < 60ml/min for > 90 days/3 months
  
  • If < 90 days may be AKI

Question 2

How is CKD classified

Answer 2

Classification includes both eGFR and urinary albumin: creatine ratio (ACR) eg. G3a A3
As raised serum creatinine reflects compromised renal function with reduced GFR

Question 3

Non-renal cause of CKD

Answer 3

Diabetes, hypertension

Question 4

what is measured to test for proteinuria, how is it quantified

Answer 4

Albumin, quantify using albumin/creatine ratio

Question 5

first line investigation in patients with albumin in dipstick

Answer 5

ACR, (then test kidney renal function)

Question 6

Treatment for proteinuria

Answer 6

ACE inhibitors and corticosteroids

Question 7

Should treatment be given if ACR is <30

Answer 7

No, may occur transiently. but need to prevent diabetic nehropathy

Question 8

What does presence of proteinuria WITH BLOOD imply
What does proteinuria in HTN imply

Answer 8

Glomerular disease (problems with filtering)
Albuminuria suggest a primary renal cause in Hypertension → SEC Hypertension

Question 9

What is nephrotic syndrome

Answer 9

• Clinical syndrome comprising oedema, heavy proteinuria, hypoalbuminemia (low levels of albumin IN BLOOD)
  
  • May not have blood in urine
    (MAINLY GLOMERULAR PROBLEMS)

Question 10

is GFR normal or abnormal in nephrotic syndrome

Answer 10

Depends on whether there is impairment of excretory function

Question 11

One sign of nephrotic syndrome, dominant symptoms

Answer 11

stretch marks in legs during protein leaking. severe lethargy, reduced exercise tolerance, nausea and loss of appetite

Question 12

What causes congenital Nephrotic syndrome

Answer 12

Mutations in nephrin in podocyte

Question 13

How are the test results in systemic vasculitis

Answer 13

Tends to have more blood than protein - indicates inflammation

Question 14

what antibody us systemic vasculitits associated with , what other symptoms

Answer 14

ANCA, May have painful lesions over joints (in both hands and feet) and rashes

Question 15

Are CKD patients more likely to be hypo or hyperkalaemic
What other drugs or diseases can exacerbate this?

Answer 15

• Hyperkalaemia common as GFR declines to less than 25
  
  • May occur at GFR > 25
    
    • Diabetes and type 4 RTA
    • ACE inhibitors → should consider reducing ACE inhibitors
    • High K Diet→ reduce consumption of high K food, increase low na food
      
      • High K diet will affect Na delivery to DCT
        Related to distal sodium delivery, decreased DND with decreased GFR

Question 16

Is acidosis or alkalaemia more likely in CKD

Answer 16

• Most Acidosis in CRF is due to animal protein in food → phosphates and sulfates generated as they break down
  
  • Inability to acidify urine in CKD

Question 17

Bone disease as complication of CKD => What types??

Answer 17

Renal osteodystrophy

• High turnover bone disease
  
  • Secondary hyperparathyroidism (Osteitis Fibrosa)
• Low turnover bone disease
  
  • Osteomalacia
    
    • Due to low calcium
  • Adynamic bone disease
  • Aluminium bone disease

Question 18

Treatment of renal osteodystrophy

Answer 18

phosphate restriction- meat and dairy , take calcium or non-calcium binders with meals, vitamin d therapy directly to override hydroxylation (alfacalcidiol), may require parthyriodectomy ??

Question 19

What risk does CKD increase?

Answer 19

CVD

Question 20

What is renal clearance? Diff vs GFR

Answer 20

VOLUME of plasma completely cleared of a substance per unit time
GFR = clearance if substance is completely lost to urine = C urine x UO / C plasma

Question 21

MDRD vs Cockcroft gault equation for estimating GFR
What are the equations

Answer 21

MDRD does not require weight, only requires plasma creatinine
Cockcroft= eGFR = (140-age) * (weight)* 1.22 or 1.04 / Cr

Question 22

What is AKI characterized by

Answer 22

Acute oliguria and increases in plasma urea and creatinine

Question 23

Normal response to water deprivation test

Answer 23

• plasma osmolality static but urine osmolality rises ( conc. of urine)
• DI→ plasma osmolality rises as urine remains dilute
  
  • CDI→ responsive to DDAVP

Question 24

What does RTA type 1 result in and how to test

Answer 24

• Renal Tubular Acidosis Type 1 (exclusively affects tubules) can lead to pH of urine being more than 5.5 (usually less than 5.5)
  
  • Due to distal tubular cells being unable to secrete H+(Abnormally permeable to H+)
• an be tested through Ammonium Chloride loading test
  
  • Used to confirm suspected RTA type I
  • NH4Cl administration leads to metabolic acidosis
  • If pH of urine> 5.5 persists then RTA type 1 confirmed

Question 25

What is pre-renal AKI

Answer 25

- Reduced real or “effective blood volume” - Kidneys are working fine but do not get sufficient blood supply

Question 26

Glomerular causes of renal AKI

Answer 26

- Rapidly progressive glomerulonephritis - Immune aetiology characterised by “glomerular crescents”

Question 27

allergic cause of tubulointerstitial damage and treatment Non allergic cause?

Answer 27

Acute allergic interstitial nephritis, - PPIs (omeprazole), antibiotics, diuretics, NSAIDs - May have eosinophilia (no rash) - Often respond well to steroids ATN- drugs, hypoperfusion eg. ACEI

Question 28

post-renal causes of AKI and first line method of exclusion

Answer 28

Obstruction, ultrasound

Question 29

what kind of AKI does myeloma cause

Answer 29

Post renal=> intra renal obstruction

Question 30

Treatment of multiple myeloma

Answer 30

- Similar to primary hyperparathyroidism, but instead of surgery: - Reduce tumour mass by chemotherapy and/ or radiotherapy (reduces bone resorption) - Consider autologous bone marrow transplant

Question 31

what protein test for myeloma

Answer 31

Bence Jones

Question 32

treatment for rapidly progresive glomerulonephrotis

Answer 32

Immunosupression

Question 33

Indications for dialysis in severe AKI

Answer 33

- Severe “uraemia” - No prospect of immediate improvement - Low amount of urine passed - Uraemic encephalopathy or seizures - Uraemic pericarditis - Hyperkalaemia unrespove to medical treatment (>6.5) - Instituted for fluid overload esp pulmonary oedema as they cannot respond to diuretics/ fluid restriction during AKI - Severe acidosis⇒ cells cant work well in myocardium, results in myocardial depression and hypotension

Question 34

What is CKD defined as

Answer 34

- GFR of < 60ml/min for > 90 days/3 months - If < 90 days may be AKI

Question 35

When is CKD diagnosed despite GFR being over 60

Answer 35

- Persistent proteinuria/microalbuminuria - Haematuria - Renal anatomical/genetic abnormality eg. biopsy-proven GN, or PKCD, or ultrasound or radiology - hypertension

Question 36

What drugs can cause CKD

Answer 36

NSAIDs, contrasts, gentamicin, phosphate enemas

Question 37

when should you test for proteinuria ( 2 disease, 1 symptom)

Answer 37

HTN, DM, Ascites/oedema

Question 38

CV complications of ESRD

Answer 38

LV hypertrophy, stroke

Question 39

Treatment of anaemia from CKD

Answer 39

- EPO replacement therapy - All patients with Hb < 105 and adequate iron stores should be on EPO - In the form of long lasting EPO, give 3 times a week if on dialysis - f poor response to EPO - Check iron stores/CRP/B12+folate/PTH/Aluminium/? malnutrition/?malignancy

Question 40

is phosphate low or high in renal osteodystrophy and why

Answer 40

High, due to increased resorption of bone. Po4 not removed properly by kidneys despite being high

Question 41

What problem can PTH result in wrt bone

Answer 41

Osteitis Fibrosa

Question 42

What happens in renal osteodystrophy if too responsive to Vit D treatment

Answer 42

Adynamic bone disease as whole bone process is shut off

Question 43

Consequences of hyperphosphataemia

Answer 43

Vascular calcification which worsens BP - Non-compliant vessels - Systolic hypertension - L Vent Hypertrophy - Diastolic hypotension - MI - Calciphylaxis - Phosphate and vascular calcification

Question 44

What is the relationship between plasma creatinine and GFR

Answer 44

Reciprocal

Question 45

How can urine Na help to determine type of AKI

Answer 45

Urine sodium can be used to determine whether tubular function is appropriate If low, suggests that tubules are appropriately re absorbing Na+ and water, may be pre-renal failure caused by hypotension. If high, suggests tubular dysfunction or damage, or inadequate aldosterone action eg. established renal failure

Question 46

Causes of hypotension not related to hypovolaemia that can cause pre-renal AKI

Answer 46

Liver failure and septic/cardiogenic shock

Question 47

Tubulointersitial causes of AKI

Answer 47

Acute tubular Necrosis -Tubular toxins eg. Gentamicin, cisplatinum,(nephrotoxic and used for cancers), NSAIDs ( limit blood flow and can be direct allogernic to kidneys) and radio- contrast dye - Severe prolonged hypotension ( sepsis or MI etc.) - Renal hypoperfusion( ACEI, ARBs, diuretics etc)

Question 48

What renal cause of AKI is related to thrombosis

Answer 48

- Haemolytic uraemic syndrome (HUS) - E.coli related ⇒ may get better

Question 49

Post renal causes of AKI

Answer 49

- Obstruction - multiple levels ⇒ Bilateral obstruction of obstruction or a single kidney ( transplant only one kidney) to result in AKI - Ureter - Calculi, tumour, extrinsic compression ( retroperitoneal fibrosis, tumour) - Bladder lesions- tumour - Stones ⇒ May have no pain at all - Prostate - hypertrophy (common), cancer - Myeloma spread to kidney ⇒ Intrarenal obstruction

Question 50

How does PTH change in mutliple Myeloma

Answer 50

suppressed due to hypercalcaemia