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Kristeen Barker Tute Renal Flashcards

1
Q

What hormones decrease phosphate

A

FGF-23 (role is purely to increase urinary phosphate excretion); PTH

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2
Q

Why is CKD-MBD an issue

A

Vascular risk

Fracture risk

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3
Q

How to classify CKD-MBD

A

High turn over bone disease - hyperparathyroidism

  • increased phosphate retention which precipitates w calcium leading to hypocalcaemia.
  • Parathyroid increases PTH, converts colecalciferol to calcitriol and increases calcium excretion from bone
  • This leads to thinning of bone
  • Also leads to tertiary hyperparathyroidism - essentially the gland has taken on its own life
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4
Q

CKD-MBD targets

A

NOrmal calicium and phosphate

PTH 2-6 x upper limit of normal

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5
Q

Management of secondary hyperparathyroidism

A
  1. Normalise phosphate - low phosphate diet + phosphate binders (aim non calcium phosphate binder because the calcium can contribute to vascular calcification); but PBS only fund for non calcium phosphate binder if on dialysis
  2. Normalise calcium if it’s still low after 1.
    - Calcitriol
    - Another indication to use calcitriol is to inhibit the PTH
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6
Q

What is tertiary hyperparathyroidim

A

PTH evelated despite high calcium - parathyroid takes a mind of its own

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7
Q

Treatment of tertiary hyperparathyroidism

A

Parathyroidectomy

Cinacalcet

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8
Q

When can calcitriol be prescribed

A

Usually only on dialysis

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9
Q

When is cinacalcet prescribed

A

On dialysis only

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10
Q

Management of osteoporosis in CKD MBD

A

> 30 treat osteoporosis as normal

<30 avoid bisphosphonates and denosumab due to risk of adynamic bone disease & hypoglycaemia

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11
Q

Mechanism of renal impairment by bisphosphonates

A

Tubular necrosis
Allergic interstitial nephritis
Direct injury to podocytes - FSGS

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12
Q

Causes of anaemia in CKD

A 
iron deficiency
increased hepcidin
decreased EPO
blood loss (from dialysis/GI bleeding)
decreased oral intake - micronutrient deficiency
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13
Q

Aetiology of iron deficiency anaemia in CKD

A

Reduced absorption
Losses - dialysis, anticoagulants, reduced red cell life span
Increased iron requirements w EPO

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14
Q

Approach to renal anaemia

A

Investigate as normal
Iron optimisation FIRST
- EPO aim for ferritin >100, TF sat >20
EPO - aim Hb 100-110 (start at 90-100)

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15
Q

How long does it take for EPO to work

A

4 weeks

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16
Q

Approach to EPO in malignancy

A

It is a growth factor stimulant

Usually curative intent avoid

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17
Q

Blood transfusions in CKD factors to consider

A
  • ?transplant candidate

- Acuity of situation

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18
Q

Side effects of sodium bicarbonate

A

Hypokalaemia/fluid overload

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19
Q

What manifestations of uraemia requires emergency dialysis

A

Pericarditis, encephalopathy

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20
Q

BP targets in CKD

A

Non proteinuric <140/90
Proteinuric <130/80
Very elderly individualise

Note in SPRINT trial showed tight control can lead to renal impairment

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21
Q

Which BB accumulates in renal failure

A

Atenolol

Bisoprolol

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22
Q

Thiazide renal side effect

A

Interstitial nephritis

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23
Q

How much change in GFR do you tolerate for commencement of RAS med

A

20% drop in GFR

24
Q

When is a statin indicated in CKD

A

> 10% CV event in 10 years
Anyone 50+ CKD at any stage

(no target LDL)

25
Evidence of statins in dialysis patients
No evidence of benefit but often cont if there are no AE | Would not start on a statin purely based on LDL
26
What OHG requires no adjustment in CKD
Linagliptin (but not sitagliptin)
27
Where is the transplanted kidney anatomically
Iliac fossa - vessels plugged into external iliacs
28
How to structure evaluation of whether a patient is a transplant candidate
Balancing patient survival vs graft survival Patient survival: - Surviving the oepration - 80% 5 yr survival - safe to immunosuppress - malignancy/infection Graft survival - Adherence - psychosocial/financial - Active disease that could affect graft - original disease recurrence (e.g. FSGS/membranous) Anatomical issues - Obesity - Peripheral vascular disease - CKD specific - PKD Immunological possible
29
What malignancy can skip the waitlist of 2-5 post active cancer for transplant
RCC
30
What is the IDEAL fluid restriction for anuric patients on HD
500mL (but often unrealistic so whatever is tolerated)
31
Life span of peritoneal dialysis
2-3 years
32
What is the ideal fluid restriction for peritoneal dialysis patients
insensible losses (500mL) + urine output + UF from PD (pt should know)
33
CKD long case presentation stage 1-3 side effects discussion
HTN, fluid overload, electrolytes
34
CKD long case presentation stage 4/5 SE discussion
HTN, fluid overload, electrolytes, CKD-MBD, renal anaemia, acidosis (save uraemia for clinical status)
35
CKD long case presentation current status/symptoms/targets
Symptoms - uraemia, cramps, restless legs, neuropathy Problems on dialysis Targets (BP) Adherence (diet, fluid restriction, meds)
36
CKD long case presentation exam
Fluid assessment, BP - link to target weight Uraemia - pericardial rub, asterixis, scratch marks Dialysis access - fistula location, thrill, bruit; PD catheter, signs of infection; Permacath
37
Glucocorticoids mechanism of immune suppression
Dampens all pathways
38
What immunosuppression dampens signal 2 (costimulation of IL-2)
Calcineurin inhibitors
39
What immunosuppression dampens signal 3 (proliferation)
mTOR mycophenolate azathioprine
40
Treatment of cell mediated acute rejection
Methylpred pulse + T-cell depleting
41
Treatment of antibdy mediated acute rejection
Pulse methylpred Plasma exchange IVIG sometimes T-cell depleting ab / rituximab
42
What the routine timeline for surveillance biopsies in kidney rejection
3 and 12 months
43
What are factors for prevention of chronic rejection
Adherence Absorption Monitoring drug levels
44
Approach to risk of rejection
Baseline and present renal function HLA mismatch DSAs (sensitising events in hx) Previous renal biopsies
45
What level of BK viral load indicates risk of BK nephropathy
10,000 copies/mL
46
How to diagnose BK nephropathy
Renal biopsy | SV40 staining positive
47
How to treat BK nephropathy
Reduce immunosuppression | IVIG
48
Mechanisms of CNI toxicity
Acute: - vasoconstriction - reversible - high drug levels Chronic: - tubulointerstitial and glomerular scarring - 100% of renal allografts at 10 years
49
Approach to chronic allograft nephropathy
``` Accumulation of immune and non immune injury Pre transplant health Rejection CNI toxicity BK nephropathy Disease recurrence AKI any cause ```
50
What are cyclosplorin specific SE
``` Gingival hyperplasia Hypertrichosis Hyepruricaemia Dyslipidaemia Hypertension ```
51
What immunosuppression is teratogenic
Mycophenolate
52
Causes of mortality post transplant
CVS - primary and secondary prevention - weight, diabetes, cholesterol Infection Malignancy - specifically virally driven cancers - annual skin check - malignancy screening as per general population Graft dysfunction
53
Immunosuppression antimicrobials post transplant
``` High dose immunosuppression: 1-2 months - nystatin/amphotericin lozenges First 6 months - bactrim - valganciclovir 3-6 months ``` Low dose maintenance - often patients are off antimicrobial after 6 months - reasons could include: after treatment for rejection, individualised risk (eg bronchiectasis), late onset CMV
54
Side effect of valganciclovir
leucopenia
55
Renal transplant examination
General inspection - tremor, cushingoid Location of graft and palpate for tenderness (infection/rejection) Listen for renal artery bruit Fistula

FRACP clinicals (24 decks)

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