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Renal > Kidney Disease > Flashcards

Kidney Disease Flashcards

1
Q

What is chronic kidney disease

A

Abnormal kidney function and/or structure
Can have normal function (e.g. U&E are fine) but will still have CKD if there is a structural problem with the kidney

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2
Q

What does CKD increase your risk of

A

Acute kidney injury
Falls
Frailty
Mortality - particularly from CVD

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3
Q

What conditions does CKD often co-exist with

A

cardiovascular disease

diabetes

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4
Q

How do you diagnose CKD

A

Raised creatinine or reduced GFR after more than 90 days

Need 2 samples at least 90 days apart

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5
Q

What are the stages of CKD

A 
G1 - normal function but structural or urine finding
G2 - mild reduction in function 
G3 - moderate reduction 
G4 - severe reduction 
G5- renal failure
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6
Q

What is the significance of albumin in the urine

A

It is a marker or endothelial or vascular disease

Its a glomerular protein

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7
Q

What does the albumin:creatinine ratio mean

A

Measure of glomerular damage

The higher the ratio the worse the disease

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8
Q

How would you follow up someone with AKI

A

Advise that they are at risk of CKD developing

Monitor for at least 2-3 after the AKI episode but should probably do lifetime

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9
Q

list risk factors for CKD

A 
Diabetes 
Hypertension 
AKI 
CVD 
Structural kidney disease 
Family History
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10
Q

what is the definition of accelerated CKD progression

A

Sustained decrease in GFR of 25% or more and a change in GFR category within a year

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11
Q

What can chronic NSAID use do to the kidneys

A

Can cause AKI

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12
Q

What is the target BP for people with CKD

A

Systolic below 140mHg

Diastolic below 90mmHg

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13
Q

What is the target BP for people with CKD and diabetes (or ACR of 70 or more)

A

Systolic below 130mmHg

Diastolic below 80mmHg

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14
Q

How do you manage ACEi or ARB treatment in CKD

A

DO NOT alter does if the GFR decrease is less than 25%

or if serum creatinine increase is less than 30%

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15
Q

How do you manage statin therapy in CKD

A

Offer Atorvastatin 20mg for CVD prevention

Increase dose if there isn’t sufficient reduction

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16
Q

List the 3 most common causes of CKD

A

Diabetes
Hypertension
Glomerulonephritides - primary or secondary

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17
Q

If you find FSGS what must you do

A

Test for blood borne viruses

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18
Q

List less common causes of CKD

A

Vascular disease - macro and micro
Tubulointerstitial problems
Calculi
Prostatic and Bladder cancer

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19
Q

List clinical signs of CKD

A 
Anaemia - pallor 
Weight loss 
Uraemia: 
- lemon yellow 
- uremic frost on skin
- twitching 
- encephalopathic flap
- confusion  
- kussmaul breathing
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20
Q

List symptoms of CKD

A 
nausea and vomiting 
anorexia 
weight loss 
fatigue 
Itch 
restless legs and muscle twitches 
confusion 
Pain - bone, nerve, visceral etc 
depression
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21
Q

List renal consequences of CKD

A

Local pain, haemorrhage, infection
Haematuria or proteinuria
Hypertension
Impaired salt, water electrolyte handling

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22
Q

List extra renal consequences of CKD

A

CVD
Mineral and bone disease
Anaemia
Nutrition

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23
Q

How do you manage CKD

A

Renal replacement therapy - dialysis or transplant

Conservative - will die eventually

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24
Q

How can you reduce CV risk

A 
Smoking cessation 
Weight loss and exercise 
Limited salt intake 
Control hypertension 
Statin
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25
Q

How does CKD lead to bone disease

A

Changes in minerals - e,g, calcium, phosphate

Increased fracture risk, pain and expansion

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26
Q

What are the consequences of mineral bone disease in CKD

A 
Bone pain 
fractures 
CV events 
Vascular calcification 
Lower QoL
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27
Q

What dietary changes can help with CKD-MBD

A

Reduce phosphate, salt, potassium, fluids

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28
Q

What medications can help with CKD-MBD

A

Phosphate binders

Active Vit D - alfacalcidol

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29
Q

How can you treat renal anaemia

A

Iron therapy

Try oral first but if it doesn’t work use IV

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30
Q

What 3 concepts are involved in dialysis

A

Diffusion
Convection
Adsorbtion

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31
Q

What is the function of dialysis

A

Allows removal of toxins which build up in end stage renal disease (urea, potassium, sodium)
Allows infusion of bicarbonate

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32
Q

How does haemodialysis work

A

Need good vascular access
Filter through the machine which has lots of microfilaments
Dialysate runs through machine which sets up gradient needed to remove toxins
Also sets up pressure gradient to remove some water

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33
Q

what does adsorption mainly affect

A

affects the plasma proteins and solutes that are bound to them
They stick to the membrane surface and then removed

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34
Q

How does hemodiafiltration work

A

mainly by convection
Add a huge volume of ultra-pure filtrate so that the pressure gradient helps remove more
Some diffusion occurs

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35
Q

Which factors affect efficacy of haemodiafiltration

A 
Water flux - rate and vol 
Membrane pore size 
Pressure difference across membrane 
Viscosity of fluid 
Size, shape and charge of molecules
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36
Q

How much fluid is used in high volume HDF

A

Replacement volume of more than 20 litres

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37
Q

How often does someone get dialysis

A

Minimum of 4 hours, 3 times a week

More effective with longer treatment time

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38
Q

What diet restrictions are put on a dialysis patient

A 
Fluid - around 1l per day 
Low salt diet 
Low potassium diet 
Low phosphate diet
Affects what you eat and how you cook etc
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39
Q

What is a tunnelled venous catheter

A

Catheter inserted into a large vein such as IJV

Can stay in for 2-3 weeks

40
Q

What are the pros of tunnelled venous catheter

A

Easy to insert

Can be immediately used

41
Q

What are the cons of tunnelled venous catheter

A

High risk of infection
Can become blocked
Can cause damage (stenosis/ thrombosis) to central veins making future line insertion difficult

42
Q

How would you diagnose and treat a catheter infection

A

Blood cultures
FBC and CRP
Swab exit site

Treat with vancomycin and gentamicin
Line removal or exchange

43
Q

What pathogen most commonly infects venous catheters

A

staph aureus

44
Q

What is the gold standard of dialysis vascular access

A

Arteriovenous Fistula

Surgically connect artery and vein

45
Q

List common sites for AV fistula

A

Radio cephalic
Brachio cephalic
Brachio basilic

46
Q

What are the pros of AVF

A

Good blood flow

Less likely to get infected

47
Q

What are the cons of AVF

A

Requires surgery
needs 6-12 weeks before use
Can limit the blood flow to distal arms
Can thrombose or stenose

48
Q

How can grafts be used in dialysis

A

Can put in a arteriovenous grfat if natural vein isn’t good enough
HeRO graft - connect graft to right atrium

49
Q

List potential complications of dialysis

A 
Hypotension - dizziness or LoC
Haemorrhage 
Loss of vascular access 
Arrhythmia 
Cardiac arrest
50
Q

How does peritoneal dialysis work

A

Solute removal by diffusion of solutes across the peritoneal membrane
Also creates an osmotic gradient to remove water
Can be done at home Either several bags a day or one that stays in all day - drained at night

51
Q

What organisms commonly cause infection in PD

A

Contamination of site - staph, strep or diptheriods

Gut bacteria translocation - E.coli or klebsiella

52
Q

How do you treat infection in PD

A

Culture the PD fluid
Give intraperitoneal antibiotics
may need to remove the catheter

53
Q

What are some potential complications of PD

A

Infection - peritonitis
Membrane failure - cant remove enough water/solutes
Hernias

54
Q

what blood test results suggest dialysis is needed

A

Resistant hyperkalaemia
eGFR < 7 ml/min
Urea > 40 mmol/L

Unresponsive metabolic acidosis

55
Q

What symptoms may suggest that dialysis is needed

A 
Nausea
Anorexia
Vomiting
Profound fatigue
Itch
Unresponsive fluid overload
56
Q

How do you start HD

A

Gradually build up

stat at 90-120 mins then increase slowly to 4hrs

57
Q

What can happen if you start dialysis too fast

A

Can lead to disequilibrium syndrome

Cerebral oedema and possible confusion, seizures and occasionally death

58
Q

How do you start up PS

A

Start with smaller fill volumes and gradually increase

Regular clinic follow ups

59
Q

Why might you withdraw from dialysis

A

Haemodynamic instability
Progressive dementia
Inability to remain on therapy for full duration due to agitation
Cardiovascular event
Terminal cancer
Increasing fraility and inability to cope at home

60
Q

What happens when you withdraw someone from dialysis

A

Palliative care

61
Q

List common symptoms of kidney disease

A 
Loin pain 
Polyuria and nocturia 
Haematuria - micro or painless macro 
Proteinuria 
Hypertension 
Fluid retention 
Bone pain 
Signs of anaemia
62
Q

Why do people with kidney disease become anaemic

A

Kidneys are responsible for producing erythropoietin

When they are damaged it affects this and it becomes defective

63
Q

How does kidney disease lead to bone pain

A

Vitamin D metabolism and phosphate excretion become abnormal
This leads on to bone pain

64
Q

What examination finding suggest kidney disease in the asymptomatic patient

A

dipstix microscopic haematuria &/or proteinuria
reduced estimated GFR on biochemical screen
raised BP
incidental findings on abdominal imaging

65
Q

List drugs that can affect renal function

A

ACEi, ARB, diuretics
NSAIDs
Antibiotics
PPI’s

66
Q

How do NSAIDs affect the kidneys

A

They decrease glomerulus pressure and decrease GFR

This causes fluid retention

67
Q

Which antibiotic is nephrotoxic

A

Gentamycin

68
Q

Why is retinopathy sometimes seen in kidney disease

A

It is a sign of DM or hypertension

Both of which can cause kidney disease

69
Q

What is accelerated hypertension

A

A medical emergency
Diastolic BP>120mmHg
Seen in young or sick patients

70
Q

List symptoms of accelerated hypertension

A 
Papilloedema 
Encephalopathy 
Fits
Cardiac failure 
Acute renal failure
71
Q

How might vasculitis present in the skin

A

Non-blanching rash

Not raised

72
Q

How can you quantify urinary protein

A

24hr urine collection

Urine protein/creatinine ratio - can be done on spot test

73
Q

Describe the different ranges for proteinuria

A

Low grade - <1g per day
Heavy 1-3g per day
Nephrotic range >3g per day

74
Q

What does a red cell urinary cast indicate

A

Pathology - usually nephritic syndrome

75
Q

What does a leucocyte urinary cast indicate

A

Infection or inflammation

76
Q

What does a granular urinary cast indicate

A

Indicator of chronic disease

77
Q

What is the ECG sign of hyperkalaemia

A

Tall tented T waves

78
Q

What causes nephrotic syndrome

A

Glomerular disease

79
Q

What are the symptoms of nephrotic syndrome

A

Proteinuria >3g per day
Hypoalbuminemia
Hypercholesterolaemia - due to overwork of liver
Oedema - everywhere!!

80
Q

What are the signs of nephritic syndrome

A

Oliguria
Oedema
Hypertension
Active urinary sediment

81
Q

What causes nephritic syndrome

A

It is the clinical syndrome of glomerulonephritis

82
Q

What gives better survival - dialysis or transplant

A

Transplant - all sources are better than dialysis

83
Q

List the different types of transplant

A

Deceased heart beating donors - brain dead
Non-beating heart donor - must be done fast
Live donation

84
Q

List contraindications for kidney transplant

A 
Malignancy 
Active HCV or HIV infection 
Untreated TB 
Severe IHD 
Active vasculitis 
Severe peripheral vascular disease 
Hostile bladder
85
Q

Patients must have a reasonable life expectancy to be suitable for transplant - true or false

A

True - must be more than 5 years

86
Q

How do you match a kidney to a recipient

A

By blood group

HLA typing - good match gives lower chance of rejection (especially in case of second transplant)

87
Q

List potential sensitising events for rejection of a transplant

A

Blood transfusion
Pregnancy or miscarriage
Previous transplant

They will have pre-formed antibodies to non-self antigens

88
Q

How are kidneys allocated

A

Paediatrics get the first offer
Then goes to an ideal match
Then a favourable match - e.g. one criteria isn’t perfect
Then any other match

89
Q

how does paired donation work

A

2 sets of live donors and recipients
The donors aren’t a match for their loved ones but are compatible with the other pairs recipient

This way both recipients get a kidney and both donors give one - just to the opposite pair

90
Q

Where is a new transplant placed

A

New kidney is grafted on to the iliac vessels - lower down

Native kidney does not come out unless causing infection or polycystic

91
Q

Describe the different levels of graft function

A

Immediate graft function - good urine output and falling creatine etc immediately
Delayed - get acute tubular necrosis and may need dialysis for a while but starts working in 10-30 days
Primary non function - never works

92
Q

What are the different types of rejection

A

Hyperacute - caused by preformed antibodies
Acute rejection - cellular or antibody mediated
Chronic - antibody mediated with slow decline in function

93
Q

what type of rejection is salvageable

A

Acute

Can be treated with increased immunosuppression

94
Q

Describe the immunosuppressive therapy needed in transplant patients

A

Start with IL-2 antagonist as induction
Prednisolone Iv in op
Then give prednisolone, tacrolimus and MMF as maintenance

95
Q

List general complications of immunosuppression

A

Infection - UTI and LRTI
CMV disease BK Nephropathy
Cancer
Post transplant lymphoproliferative disease - EBV

Renal (18 decks)

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