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CKD and ESKD Flashcards

1
Q

What is the primary process by which solutes will be removed by PD?

A

Diffusion and convection

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2
Q

What is the recommended minimum weekly Kt/V in PD?

A

Kt/V of 1.7 (it is the minimum, not the target!)

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3
Q

What are the benefits of frequent hemodialysis? (hint: 4)

A
  1. less LVH
  2. better HTN control
  3. better control of hyperphosphatemia
  4. better volume control
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4
Q

What are the risks of frequent hemodialysis? (hint: 5)

A
  1. vascular access trauma
  2. less residual kidney function
  3. increased burden on the patient and caregiver
  4. more expense
  5. more intradialytic hypotension
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5
Q

True or False
Renal and Peritoneal clearance equally contribute when calculating Kt/V in PD

A

TRUE

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6
Q

What are the long term complications of uremia (hint: 4)

A
  1. dialysis acquired amyloidosis
  2. accelerated CV risk
  3. uremic platelet dysfunction
  4. Immunodeficiency
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7
Q

How can you improve ultrafiltration in PD?

A

increasing dextrose concentration

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8
Q

What are ways to improve PD clearance? (hint: 3)

A
  1. increase the fill volume
  2. increase the # of exchanges
  3. optimize the dwell time
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9
Q

what is the only diuretic other than spironolactone that can be used by a patient with sulfa allergy?

A

ethacrynic acid

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10
Q

What is the minimum sp KT/V recommended in patients doing 3x/weekly intermittent HD?

A

sp Kt/V of 1.2, but better if the sp Kt/V is 1.4

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11
Q

what is the cause of the cough a/w ACEI?

A

Bradykinin. the inhibition of ACE causes bradykinin to accumulate in the airways

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12
Q

which ACE inhibitor is poorly dialyzed

A

Fosinopril

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13
Q

Which class of drugs are dialyzable? ACEi or ARBs?

A

ACEI are dialyzable, ARBs are not.

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14
Q

why are ARBs preferred over ACEi in the CKD population?

A

ARBs have shown to produce a greater decrease in CVE than ACEi, especially among patients with established CVD. (LIRICO trial)

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15
Q

to avoid clotting in postdilution CVVH, what threshold should you keep the filtration fraction under?

A

under 25%

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16
Q

during CRRTm what risk develops when the ratio of total calcium to iCa is > 2.5?

A

citrate toxicity

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17
Q

what is the treatment for BZD overdose?

A

Flumazenil (a BZD antagonist)

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18
Q

which toxic alcohol is found in rubbing alcohol?

A

isopropyl alcohol. It’s also found in hand sanitizer.
Windshield washer contains methanol
Deicing fluid/antifreeze contains athylene glycol

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19
Q

name 2 glomerular syndromes that can be present in liver disease.

A

IgAN; cryoglobulinemia; MPGN

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20
Q

what is expected to be present in the urine of a patient who ingested ethylene glycol?

A

calcium oxalate crystals

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21
Q

what is a risk a/w rasburicase?

A
  1. G6PD deficiency (always check for GP6PD levels prior to starting it)
  2. methemoglobinemia
  3. anaphylaxis
  4. Abs develop in 10-20%
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22
Q

True or False. There is benefit in starting RRT earlier rather than later in ICU patients

A

False. There is no conclusive benefit (STARRT AKI, AKIKI 1)

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23
Q

Which form of CRRT anticoagulation has the greatest success in preventing circuit clotting?

A

citrate

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24
Q

what is the renal injury that causes AKI with use of the drug ecstasy?

A

Rhabdomyolysis. Hyponatremia is also common

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25
Q

name a drug that will lower creatinine clearance but not true GFR. (Bonus: name 4)

A

trimethoprim (Bactrim) and cimetidine, cobicistat, dolutegravir. They inhibit tubular secretion of creatinine via OCT2

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26
Q

name 3 risk factors for dialysis disequilibrium syndrome (bonus: 7)

A
  1. first treatment 2. young/old 3. very high BUN 4. hypernatremia 5. hyperglycemia 6. metabolic acidosis 7. preexisting neurologic abnormalities
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27
Q

predilution CVVH will (increase/decrease) clearance, (increase/decrease) clotting?

A

decrease clearance, decrease clotting

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28
Q

what is caused by excessive chloramines in the dialysate during iHD?

A

Hemolysis

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29
Q

what is the base source of HCO3 in PD dialysate?
1. acetate
2. citrate
3. lactate

A

Lactate

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30
Q

name 2 situations that may necessitate urine alkalinization?

A
  1. uric acid stones
  2. methotrexate overdose
  3. salicylate overdose
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31
Q

which CRRT modality has the highest clearance assuming the effluent rate is the same?
1.CVVH predilution
2. CVVH postdilution
#. CCHDF predilution

A

CVVH post dilution. predilution lessens clotting but will decrease clearance because some of the effluent is replacement fluid.

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32
Q

name 3 potential electrolyte complications when using citrate in CRRT?

A

hypocalcemia, metabolic alkalosis (citrate in excess), metabolic acidosis (citrate toxicity), hypercalcemia (excess calcium drip), hypernatremia (trisodium citrate formulation)

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33
Q

what is the pressure threshold that defines abdominal compartment syndrome?

A

> 20 mmHg; >12 mmHg defines intraabdominal hypertension

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34
Q

name a histological findings of ATN

A
  1. loss of the PT brush border
  2. granular casts in tubules
  3. tubular cell mitoses
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35
Q

what is the treatment for acyclovir-associated AKI?

A

hemodialysis

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36
Q

AKI in myelomonocytic leukemia is related to the overproduction and excretion of what LMWP?

A

lysozyme

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37
Q

which drug is a/w G6PD related hemolysis?
1. rasburicase
2. rituximab
3. INH
4. quinine

A

rasburicase

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38
Q

name 2 causes of hemoglobinuric AKI

A
  1. transfusion reaction
  2. P. falciparum malariae
  3. mechanical heart valve
  4. PNH
  5. trauma from exercise/ prolonged standing
  6. hantavirus
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39
Q

name the renal pathologic finding in snake bite related AKI which is common in Asia.

A

TMA or cortical necrosis

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40
Q

match the bisphosphonate with the renal lesion
1. pamidronate 2. zolendronate
A. collapsing FSGS, B. ATN

A

pamidronate - collapsing FSGS
zolendronate - ATN

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41
Q

match the ff
1. cisplatin 2. Mitomycin C & gemcitabine 3. VEGFi
a. HUS/TMA. b. hypoMg

A

1B, 2A 3A

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42
Q

whcih common additive to cocaine can cause ANCA associated vasculitis?

A

levamisole

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43
Q

true or false
iHD can prevent contrast associated nephropathy

A

False

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44
Q

which contrast medium has the lowest osmolality, iso-osmolar or low-osmolar?

A

iso-osmolar
Low-osmolar contrast is still high at 320-800 mOsm/L, vs iso-osmolar contrast which is 290 mOsm/L

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45
Q

what is the purpose of the furosemide stress test?

A

to prognosticate among those with AKI II or III if they will end up needing dialysis. In AKI, an increase in UOP after lasix indicates an improved prognosis

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46
Q

name a cause of osmotic nephrosis

A
  1. IVIG if with sucrose formulation
  2. mannitol
  3. SGLT2 inhibitors
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47
Q

an elderly patient develops AKI after a routine colonoscopy. what may be present on renal biopsy?

A

CaPO4 deposition in renal tubules. this scenario is less common since the d/c of oral phosphate-based bowel prep.

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48
Q

what is the easiest wat to diagnose pseudo AKI from a urine leak into the abdomen?

A

send urine ascites for creatinine analysis; the result will be greater than the serum creatinine value

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49
Q

what antibiotic increases the risk of AKI when given with vancomycin?

A

Pip-tazo

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50
Q

name a balanced IVF

A

LR and plasmalyte

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51
Q

what kind of urine pH is MTX most likely to cause crystals?

A

acidic urine

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52
Q

name one situation where CRRT would be better than iHD?

A

high intracranial pressure

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53
Q

Mnemonic for CYP450 inducers
CRAPS out drugs

A

Carbamazepine, rifampicin, bArbiturates, Phenytoin, St. John’s wort

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54
Q

match the hyperK treatement with the AE:
1. Patiromer, 2. Lokelma
a. hypoMg, b. edema

A

patiromer: hypomG
lokelma: edema

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55
Q

how does heparin cause hyperK?

A

heparin (-) aldosterone release. therefore less K secretion in the CD

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56
Q

in hypokalemic periodic paralysis, which characteristic fits best?
1. asian male & hyperthyroidism
2. asian female & hyperthyroidism
3. licorice ingestion

A

Asian male and hyperthyroidism

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57
Q

fill in the blank with 3 electrolytes
Refeeding results in low ___

A

Low phosphate, potassium, magnesium

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58
Q

Name the acid or metabolic acidosis associated with each of these:
1. acetaminophen
2. linezolid
3. SGLT2 inhibitor

A

acetaminophen = HAGMA (cause of oxoproline)
Linezolid = HAGMA, lactic acidosis
SGLT2i = beta hydroxybutyrate

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59
Q

ingestion of isopropyl alcohol results in which of the ff?
1. NAGMA
2. Ketoacidosis
3. ketosis without acidosis

A

Ketosis without acidosis
Isopropyl alcohol gets metabolized to acetone. Ketones are very weak acids and do not cause acidosis

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60
Q

how does omperazole (PPIs) result in hypomagnesemia?

A

PPIs decreases GI absorption og Mg by inhibiting TRPM6 chain. Renal Mg can. below.

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61
Q

what is the flow of a high output AVF?

A

flow > 1500 ml/min

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62
Q

VEGF inhibitors (e.g. bevacizumab) and axitinib (TKI) are metabolized by CYP450, so what antihypertensives should be avoided?

A

non-DHP CCBs (e.g. verapamil, diltiazem) nifedipine because they inhibit CYP450; nifedipine because they cause VEGF expression

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63
Q

what is the most likely diagnosis in a patient with ESKD presents with hip pain, xray shows a lytic lesion on the pelvis, PTH is 1500 pg/mL, Ca 8.4, PTH 4.8?

A

osteitis fibrosa cystica (aka brown tumor)

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64
Q

Match
1. Cat contamination
2. Bird contamination
3. Sheep or cows

A. Brucella spp
B. Fungal
C. Pasteurella spp

A

1, C
2, B
3, A

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65
Q

Treatment for eosinophilic peritonitis (aka peritoneal eosinophilic serositis)

A

Oral antihistamines
Systemic steroids, if persistent

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66
Q

What is High venous pressure in the CRRT?

A

Pressure > 250 mmHg

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67
Q

Causes of high venous pressure in CRRT

A

Kinks, thrombus in the catheter, central vein stenosis, clotting in the dialyzer

68
Q

What is the best way to prevent access thrombosis?

A

Aspirin and dipyrimadole

69
Q

What is the minimum diameter for veins to predict AVF maturation?

A

Minimum of 2.5 mm

70
Q

Name 2 ACEi that are dialyzable & 2 that are non-dialyzable

A

Dialyzable: lisinopril, captopril
Non-dialyzable: benazepril, fosinopril

71
Q

are CCBs dialyzable or non-dialyzable?

A

Non-dialyzable

72
Q

Which CNI causes hirsutism and gingival hyperplasia?

A

Cyclosporine

73
Q

Which CNI causes hair loss and post-transplant diabetes?

A

Tacrolimus

74
Q

What are the major side effects of AZT? (Hint: 3)

A

bone marrow suppression, veno-occlusive disease, pancreatitis

75
Q

What are the major side effects if
mTOR inhibitors?

A

BM suppression, delayed wound healing, hyperlipidemia, lymphedema, proteinuria (FSGS)

76
Q

What is the PO to IV conversion of CsA and TAC?

A

IV is 1/3 the oral dose

77
Q

What is the PO to SL dose conversion if TAC?

A

SL dose is 1/2 the PO dose

78
Q

At what level of CrCl should edoxaban NOT be used?

A

Edoxaban should NOT be used if CrCl is > 95 ml/min. In the ENGAGE AF-TIMI trial, patients with a CrCl of > 95 had an increased rate of ischemic stroke vs warfarin

79
Q

What life threatening side effects can occur if you combine clonidine + beta blockers?

A

Severe bradycardia, asystole

80
Q

Poison case.
What drugs can be removed by dialysis?

A
  1. Salicylate
  2. Lithium
  3. Alcohols - methanol, ethylene glycol, isopropyl alcohol
  4. Theophylline
  5. Valproate
  6. Methotrexate
  7. Phenobarbital
  8. Metformin
81
Q

What is the treatment of choice for acetaminophen poisoning?

A

N-acetylcysteine
- it will prevent or alleviate the hepatotoxicity by restoring hepatic glutathione stores

82
Q

What is the indication for HD in the case of alcohol poisoning?

A

Do iHD if the alcohol level is > 50 mg/dL, severe metabolic acidosis or end-organ damage

Use large surface area dialyzers (>1.5 m2) along with high Qb > 300 ml/min

83
Q

At what GFR is metformin contraindicated?

A

Stop or do not give metformin if GFR < 30

84
Q

Hemodialysis is indicated in metformin lactic acidosis if the ff is present:

A
  1. Lactate level > 20
  2. Severe metabolic acidosis pH < 7.0
  3. Medical treatment failure - no response to sodium bicarbonate
85
Q

Glutamine, the substrate for NH3, is taken up by the proximal tubular cells via _____

A

SNAT3 (sodium dependent amino acid transporters)

86
Q

what syndrome has presents with goiter, sensorineural deafness, and metabolic alkalosis

A

pendred syndrome

87
Q

What is the defect or mutation in Pendred syndrome?

A

Defective pendrin or the Cl/HCO3 exchanger in the beta intercalated cells of the CD

88
Q

What is the appearance of blood in the venous line during HD when there is chloramine contamination?

A

“portwine” appearance

89
Q

s/sx of lead nephropathy

A

classic triad: HTN, gout, CKD,
others: cognitive impairment, peripheral neuropathy, microcytic anemia, proximal tubulopathy

90
Q

occupational hazard for lead nephropathy

A

esp. battery workers,
others: smelting, paint removal, fuel, paint, and ammunition production

91
Q

alcoholic drink that can be a risk factor for lead nephropathy

92
Q

what are risk factors for calciphylaxis?

A

warfarin, diabetes, insulin > 3x/d

93
Q

what is the treatment for calciphylaxis that is given during iHD

A

sodium thiosulfate
dose is 12.5 g per iHD if wt < 60kg
dose is 25 g per iHD if wt > 60kg

94
Q

what is the size cutoff for tumor excision in patients with renal cysts related to vHL?

A

tumors >/= 3 cm may be excised; < 3 cm observe

95
Q

at what age do we start screening for renal manifestations in vHL?

A

screen by age 10

96
Q

definition of UF failure in PD?

A

inability to achieve > 750 mL of UF in an anuric PD patient

97
Q

what is the rule of 4 in PD UF failure?

A

UF of < 400 mL after a 4 hour dwell of 2 L of 4.25% dextrose

98
Q

in the water treatment system, what is the role of a water softener?

A

it removes positively charged ions (e.g. Ca, Mg, Heavy metals) from the water to prolong the life of the RO system

99
Q

in the water treatment system, what removes the positively charged ions?

A

water softener

100
Q

in the water treatment system, what is the role of the carbon tanks?

A

it removes chlorine and chloramine or other organic solvents

101
Q

how often should the carbon tanks be tested?

A

before every shift or every 4 hours

102
Q

exhaustion or malfunction of the carbon tanks will result in?

103
Q

in the water treatment system, what is the role of RO?

A

it removes metal ions, aqueous salts, bacterai and viruses based on charge and MW

104
Q

what is the role of a deionizer in the water treatment system?

A

it exchanges H+ and anions for OH- to form H2O

105
Q

exhaustion or dysfunction of the deionizer will result in?

A

Fluoride or copper accumulation

106
Q

in the water treatment system, what is required if deionization or UV light is used?

A

micron ultrafilter - removes bacteria and exotoxins

107
Q

how do you calculate for extraction ratio of BUN during dialysis?

A

[preBUN - postBUN]/preBUN x 100

108
Q

what is the formula for dialysis clearance (Kd) of BUN after hemodialysis?

A

Dialysis clearance = Extraction ratio x Blood flow

since Extraction ratio is never >1, therefore Clearance will never exceed blood flow

109
Q

How to assess if a patient is getting adequate clearance while on intermittent hemodialysis?

A

measure weekly Kt/V (std Kt/V)
K is the Kd of urea
Kd urea = [(pre BUN - post BUN)/preBUN] x Qb
T is time on dialysis
V is the Vd of urea = TBW x 0.5

110
Q

what is the capillary blood flow rate in the peritoneum?

A

50-100 ml/min

111
Q

Majority of the pores in the peritoneum are ultrapores, small pores or large pores?

A

Small pores (95%)

Ultrapores compres 3%, large pores comprise 2%

112
Q

TRUE or FALSE.
The PET test is used to determine overall survival, PD success or outcome.

113
Q

the PET test is done to assess what?

A

to assess peritoneal membrane characteristics which can help dictate the PD prescription

114
Q

what is the management for patients with a stenosis at the fistual anastomosis or draining vein?

A

angioplasty or surgical revision

115
Q

what is the management for a fistula with a large accessory vein?

A

surgical ligation

116
Q

what is the management for a deep fistula?

A

superficialization

117
Q

what is the depth (mm) of a deep fistula

A

found > 5mm away from the skin surface

118
Q

what is the incidence of AVF non-maturation?

A

20-60% ( was 60% in the DAC study)

119
Q

what are associated risk factors for fistula non-maturation?

A

female, elderly, PAD, forearm, h/o PICC lines or CVC, IVDU,

120
Q

Preoperative mapping of arm veins will decrese the rate of non-maturation of AVF
True or false?

A

False.

it only allows for more patients to get an AVF, but the rate of non-maturation persists

121
Q

what arterial diameter is considered ideal for AVF creation?

A

2.0 mm and above

122
Q

what venous diameter is ideal for AVF creation?

A

2.5 mm and above

123
Q

AVF matures usually at how many weeks post-op?

124
Q

what is the US criteria for ADPKD diagnosis in a PKD1 family or if +FHx for ESRD < 55 in a patient who is < 30 years old?

A

at least 2 cysts in either or both kidneys

125
Q

what is the US criteria for ADPKD diagnosis in a PKD1 family or if +FHx for ESRD < 55 in a patient who is 30-59 years old?

A

at least 2 cysts per kidney

126
Q

what is the US criteria for ADPKD diagnosis in a PKD1 family or if +FHx for ESRD < 55 in a patient who is > 60 years old?

A

at least 4 cysts per kidney

127
Q

what is the US criteria for ADPKD in family of unknown genotype in a patient who is 15-39 years old?

A

at least 3 cysts in either or both kidneys

128
Q

what is the US criteria for ADPKD in family of unknown genotype in a patient who is 40-59 years old?

A

at least 2 cysts per kidney

129
Q

what is the US criteria for ADPKD in family of unknown genotype in a patient who is >60 years old?

A

at least 4 cysts per kidney

130
Q

What is the US criteria to rule out ADPKD?

A

age 40 and above with < 2 cysts total

131
Q

what has a worse prognosis? truncating or non-truncating PKD1 mutation?

A

truncating PKD1 mutation

132
Q

what has a better prognosis, PKD1 or PKD2 mutation?

A

PKD2 mutation
- later onset, smaller TKV, less cysts, later onset of ESKD

133
Q

what is the mutation in ADPKD?

A

PKD1 and PKD2

134
Q

what are other mutations with ADPKD like phenotype? (2)

A

GANAB and DNAJB11

135
Q

A patient with bilateral kidney cysts, preserved kidney function, and mild to severe polycystic liver disease is a/w ____?

GANAB or DNAJB11?

136
Q

A patient with normal sized kidney but with multiple cysts, slow evolution to ESKD and absent-moderate polycystic liver disease is a/w?

GANAB or DNAJB11?

137
Q

what is the indication for tolvaptan use in a patient with ADPKD?

A

those with Mayo Class 1C, 1D, 1E witj rapidly progressive ADPKD, eGFR > 25 ml/min

138
Q

tolvaptan is contraindicated in what situation?

A

liver failure or elevated liver enzymes

139
Q

how will you monitor liver function test in a patient on tolvaptan?

A

measure LFTS at baseline, then 2 weeks, 4 weeks and every month for 18 month, then every 3 months thereafter

140
Q

what is the target urine osmolality in ADPKD>?

A

urine osm < 280

141
Q

according to the HALT PKD study, what is the target BP in ADPKD patients with eGFR > 60 vs eGFR < 60?

A

eGFR 60: intensive BP control < 110/75

eGFR < 60: BP goal < 130/80

intensive BP control is a/w 14.2% slower rate of TKV growth over 5 years

142
Q

What is the preferred order of the class of antiHTN meds in PKD?

A

ACEi or ARBS > beta blocker > alpha blocker > DHP CCB > Diuretics

143
Q

What percentage most closely reflects the prevalence of biopsy proven AIN in patients witH AKI?

144
Q

What is the goal Hba1C for patients who are diabetic but are pregnant?

A

Goal HbA1C is < 6.5%
(Strict metabolic control)
30% increased risk for fetal malformations for every increase of 1% in HbA1c

145
Q

What is the risk of CKD progression in patients with known FSGS who becomes pregnant if the serum crea is > 2.4, proteinuria is > 3g/d?

A

> 50% risk of CKD progression during pregnancy or within 6 months post-partum

146
Q

Using sucralfate will increase the risk for what type of toxicity?

A

Aluminum toxicity

147
Q

What are the signs and symptoms of aluminum toxicity?

A

neurologic symptoms, bone pain, fractures, hypercalcemia, EPO hyporesponsiveness, dementia

148
Q

Sodium azide exposure can cause ____?
A. Seizures
B. Hypotension
C. Hemolysis

A

Hypotension

149
Q

Dialysis water exposed to agricultural run-off or well-water can increase the risk for ___ toxicity?
A. Nitrate toxicity
B. Lead Toxicity
C. Copper Toxicity

A

Nitrate toxicity

150
Q

Methhemoglobinemia can be caused by ___ toxicity and exposure to what type of cleaning agent?

A

Nitrate toxicity & hydrogen peroxide

151
Q

What are the signs and symptoms of hydrogen peroxide exposure?

A

methemoglobinemia, nausea, abd pain, back pain, hemolysis

152
Q

what is the treatment for methemoglobinemia?

A

methylene blue

153
Q

What is the safe fluoride cut-off?

A

Fluoride < 0.2 PPM

154
Q

what level of fluoride is associated with death?

A

Fluoride levels > 15 PPM

155
Q

What is the definition of immunity to Hepatitis B?

A

HbsAb titers of > 10 IU/L

156
Q

How often should HbsAg be tested for ESKD patients who are immune to HBV?

A

annual testing

157
Q

How often should HbsAg be tested for ESKD patients who are not immune to HBV?

A

monthly testing

158
Q

What are concerning features for renal cell carcinoma if you see cysts in an ESKD patient?

A

size > 3 cm or septations

159
Q

What study will you request if a patient has a 3cm renal cyst with septations on US?

A

get a CT scan or MRI to evaluate for renal cell carcinoma

160
Q

What level of serum potassium is associated with high mortality rates among ESKD patients?

A

serum potassium > 5.7 mEq/L

161
Q

what level of pre-dialysos serum potassium is associated with the lowest mortality?

A

serum K of 4.6-5.3 mEq/L

162
Q

What is the estimated length of survival (days) if an ESKD patient decides to stop dialysis?

163
Q

what are the values of D/P creatinine and D/P glucose of high or fast transporters?

A

D/P creatinine > 0.6 to 0.8
D/P glucose is < 0.4

164
Q

what are the values of D/P Creatinine and D/P Glucose of low or slow transporters?

A

D/P creatinine is < 0.5 to 0.6 and D/P glucose is > 0.4

165
Q

what are the benefits of icodextrin? (4)

A
  1. better UF = better BP control
  2. Better phosphate control
  3. better lipid profile
  4. longer technique survival

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