FY1 Renal Medicine Flashcards
Fluid status.
a) Components of an examination
b) Supporting features
a) Peripheral oedema, JVP, mucous membranes, HS, lung bases
b) - Vitals - BP, HR, postural drop, low O2, high RR
- Symptoms - SOB, orthopnoea, headaches, dizziness, falls, etc.
Haemodialysis
a) Access
b) Maximal UF rate
c)
a) AV fistula, temporary femoral line (5 days max), long-term TNL
b) 10 mls/kg/hr
- 700 mls/hr in a 70kg person
= ~ 3L for a 4 hour dialysis session
Clotted fistula
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Recirculation problems/studies
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Peritoneal dialysis
a) 2 basic types
b) Bag strength
c) Average time on PD before other RRT necessary
a) - CAPD - not actually continuous, but patient does exchanges through the day (usually around 4)
- APD -
b) - Higher strength = more glucose = more UF
- However, also leads to greater scarring of the peritoneum and shortens lifespan of PD
c) 10 years
PD peritonitis.
a) Presentation
b) Ix
c) Rx
a) - Abdo pain
- Cloudy effluent
- Exit site infection
- Tunnel erythema, etc.
b) - PD sample - culture and WCC (o/a and day 3)
- Bloods -
c) - Empirical - IP gent + vanc
- G -ve - IP gentamicin, PO cipro
- G +ve - IP vancomycin
- Fungal - take out PD catheter, treat with antifungals
Line sepsis
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Central stenosis
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Transplant workup
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Investigations in renal patients.
a) Bedside
b) Bloods
c) Imaging
d) Special tests
a) - Urine dip
- UPCR
b) - FBC, U+E, CRP, clotting, LFTs, Mg
- Haematinics - B12, folate, ferritin, iron sats
- Bone profile - Ca, Phos, PTH, vit D
- Anion gap / VBG (acid-base)
- Antibodies - IgA, CTD screen (ANA, C3/C4), vasculitis screen (ANCA), anti-GBM
- Serology - HIV, Hep B, Hep C
- Transplant - CMV, PJP, BK, JC, beta-D-glucan
c) - Renal US
- Vascular US - for venous patency
- Transplant US (trans-scan)
d) - Renal biopsy
- PD sample - WCC and culture
- Recirculation studies
Renal biopsy - workup
a) Before
b) After
a) - Ensure BP < 140/90
- Ensure Hb > 90
- Stop anticoagulants (including prophylactic dose LMWH) the day before
- Ensure patient can lie flat
b) 6h
Line insertion - workup
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TNL line removal
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Anion gap.
a) Equation
b) Normal range
c) Explanation of normal/high anion gap acidosis
d) Causes of high anion gap metabolic acidosis
e) Causes of normal anion gap metabolic acidosis
f) Type in renal failure
a) [Na (+ K)] - [Cl + HCO3]
b) 8 - 16
c) High anion gap:
- H+ build up leads to consumption of HCO3
- Leads to high anion gap
Normal anion gap:
- HCO3 loss is balanced by retention of Cl, anion gap remains normal
- i.e. hyperchloraemic metabolic acidosis
d) - DKA
- Lactic acidosis (e.g. sepsis)
- Uraemia
- Poisoning - salicylates, methanol
e) - GI losses
- Renal tubular acidosis
f) - May be normal or high
- Generally high if there is significant uraemia
Renal anaemia.
a) Physiology
b) Workup
c) Treatments
d) Target Hb range
a) EPO deficiency - Normocytic anaemia (anaemia of chronic disease)
May also have B12/folate deficiencies
b) - FBC, haematinics (iron studies, B12, folate)
c) - Darbepoetin* (Aranesp) - SC or IV via dialysis
- IV iron* - monofer (low volume, expensive), diafer, (on dialysis), cosmofer (higher volume, cheap)
*Starting dose = 0.45 micrograms/kg
**Note: iron deficiency must be corrected or EPO will not work; avoid during infection as will not be effective and can worsen infection
d) 100 - 120
Renal mineral and bone disease
a) Physiology
b) Treatments
c) PTH target range
d) Dialysis patients - what can be done?
a) - Impaired vitamin D activation - causes reduced Ca / PO4 absorption in the gut
- Impaired renal excretion of phosphate (high PO4)
- Secondary hyperparathyroidism - low Ca and high PO4 leads to raised PTH levels - increases osteoblast and osteoclast activity, and increased bone resorption
- Chronically high PTH causes renal osteodystrophy:
Osteoporosis/fractures
Osteomalacia
Osteitis fibrosa cystica
- Chronic secondary hyperPTH-ism can lead to tertiary hyperPTH-ism* (high PTH, HIGH Ca, high PO4)
b) - DIET - low phosphate
- 1st line - Phosphate binders - calcium containing (e.g. calcium carbonate/calci-chew/AdCal or calcium acetate), non-calcium containing (e.g. sevelamer, lanthanum)
- 2nd line - If PTH still high - add Vitamin D - alfacalcidol (activated) or cholecalciferol
- 3rd line - If still high - cinacalcet (calcimimetic - mimics calcium to reduce serum PTH) or parathyroidectomy
c) Between 2-9x normal
(lower levels can cause fractures)
d) Change amount of calcium in dialysate
* Note: look out for primary hyperPTHism, leading to: high PTH, high Ca, low PO4
Iron deficiency.
a) Diagnosis
b) Treatment
c) Induction regime for dialysis patients
d) Maintenance regime
a) Iron studies - iron sats < 20%
b) Oral iron - generally not effective in ESRF
IV iron - monofer, cosmofer, diafer
c) 100mg on every dialysis session for 10 sessions
d) 100mg weekly on dialysis
Transplant patients.
a) Problems
b) Investigations
a) - Transplant rejection
- Transplant AKI
- Immunosuppression - opportunistic infections (e.g. CMV, PJP, BK virus)
b) - General renal workup (dipstick, renal chemistry, etc)
- Special: CMV, PJP, BK, JC, beta-D-glucan
- Abdo/Renal US and transplant US
- Transplant biopsy
Calciphylaxis (SD)
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Vasculitis (EJ)
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Anti-GBM
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