Kristeen Barker Tute Renal Flashcards
What hormones decrease phosphate
FGF-23 (role is purely to increase urinary phosphate excretion); PTH
Why is CKD-MBD an issue
Vascular risk
Fracture risk
How to classify CKD-MBD
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
CKD-MBD targets
NOrmal calicium and phosphate
PTH 2-6 x upper limit of normal
Management of secondary hyperparathyroidism
- 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
- Normalise calcium if it’s still low after 1.
- Calcitriol
- Another indication to use calcitriol is to inhibit the PTH
What is tertiary hyperparathyroidim
PTH evelated despite high calcium - parathyroid takes a mind of its own
Treatment of tertiary hyperparathyroidism
Parathyroidectomy
Cinacalcet
When can calcitriol be prescribed
Usually only on dialysis
When is cinacalcet prescribed
On dialysis only
Management of osteoporosis in CKD MBD
> 30 treat osteoporosis as normal
<30 avoid bisphosphonates and denosumab due to risk of adynamic bone disease & hypoglycaemia
Mechanism of renal impairment by bisphosphonates
Tubular necrosis
Allergic interstitial nephritis
Direct injury to podocytes - FSGS
Causes of anaemia in CKD
iron deficiency increased hepcidin decreased EPO blood loss (from dialysis/GI bleeding) decreased oral intake - micronutrient deficiency
Aetiology of iron deficiency anaemia in CKD
Reduced absorption
Losses - dialysis, anticoagulants, reduced red cell life span
Increased iron requirements w EPO
Approach to renal anaemia
Investigate as normal
Iron optimisation FIRST
- EPO aim for ferritin >100, TF sat >20
EPO - aim Hb 100-110 (start at 90-100)
How long does it take for EPO to work
4 weeks
Approach to EPO in malignancy
It is a growth factor stimulant
Usually curative intent avoid
Blood transfusions in CKD factors to consider
- ?transplant candidate
- Acuity of situation
Side effects of sodium bicarbonate
Hypokalaemia/fluid overload
What manifestations of uraemia requires emergency dialysis
Pericarditis, encephalopathy
BP targets in CKD
Non proteinuric <140/90
Proteinuric <130/80
Very elderly individualise
Note in SPRINT trial showed tight control can lead to renal impairment
Which BB accumulates in renal failure
Atenolol
Bisoprolol
Thiazide renal side effect
Interstitial nephritis
How much change in GFR do you tolerate for commencement of RAS med
20% drop in GFR
When is a statin indicated in CKD
> 10% CV event in 10 years
Anyone 50+ CKD at any stage
(no target LDL)
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
What OHG requires no adjustment in CKD
Linagliptin (but not sitagliptin)
Where is the transplanted kidney anatomically
Iliac fossa - vessels plugged into external iliacs
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
What malignancy can skip the waitlist of 2-5 post active cancer for transplant
RCC
What is the IDEAL fluid restriction for anuric patients on HD
500mL (but often unrealistic so whatever is tolerated)
Life span of peritoneal dialysis
2-3 years
What is the ideal fluid restriction for peritoneal dialysis patients
insensible losses (500mL) + urine output + UF from PD (pt should know)
CKD long case presentation stage 1-3 side effects discussion
HTN, fluid overload, electrolytes
CKD long case presentation stage 4/5 SE discussion
HTN, fluid overload, electrolytes, CKD-MBD, renal anaemia, acidosis (save uraemia for clinical status)
CKD long case presentation current status/symptoms/targets
Symptoms - uraemia, cramps, restless legs, neuropathy
Problems on dialysis
Targets (BP)
Adherence (diet, fluid restriction, meds)
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
Glucocorticoids mechanism of immune suppression
Dampens all pathways
What immunosuppression dampens signal 2 (costimulation of IL-2)
Calcineurin inhibitors
What immunosuppression dampens signal 3 (proliferation)
mTOR
mycophenolate
azathioprine
Treatment of cell mediated acute rejection
Methylpred pulse + T-cell depleting
Treatment of antibdy mediated acute rejection
Pulse methylpred
Plasma exchange
IVIG
sometimes T-cell depleting ab / rituximab
What the routine timeline for surveillance biopsies in kidney rejection
3 and 12 months
What are factors for prevention of chronic rejection
Adherence
Absorption
Monitoring drug levels
Approach to risk of rejection
Baseline and present renal function
HLA mismatch
DSAs (sensitising events in hx)
Previous renal biopsies
What level of BK viral load indicates risk of BK nephropathy
10,000 copies/mL
How to diagnose BK nephropathy
Renal biopsy
SV40 staining positive
How to treat BK nephropathy
Reduce immunosuppression
IVIG
Mechanisms of CNI toxicity
Acute:
- vasoconstriction
- reversible
- high drug levels
Chronic:
- tubulointerstitial and glomerular scarring
- 100% of renal allografts at 10 years
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
What are cyclosplorin specific SE
Gingival hyperplasia Hypertrichosis Hyepruricaemia Dyslipidaemia Hypertension
What immunosuppression is teratogenic
Mycophenolate
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
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
Side effect of valganciclovir
leucopenia
Renal transplant examination
General inspection - tremor, cushingoid
Location of graft and palpate for tenderness (infection/rejection)
Listen for renal artery bruit
Fistula
