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FRACP clinicals > Kristeen Barker Tute Renal > Flashcards

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
Q

Evidence of statins in dialysis patients

A

No evidence of benefit but often cont if there are no AE

Would not start on a statin purely based on LDL

26
Q

What OHG requires no adjustment in CKD

A

Linagliptin (but not sitagliptin)

27
Q

Where is the transplanted kidney anatomically

A

Iliac fossa - vessels plugged into external iliacs

28
Q

How to structure evaluation of whether a patient is a transplant candidate

A

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
Q

What malignancy can skip the waitlist of 2-5 post active cancer for transplant

A

RCC

30
Q

What is the IDEAL fluid restriction for anuric patients on HD

A

500mL (but often unrealistic so whatever is tolerated)

31
Q

Life span of peritoneal dialysis

A

2-3 years

32
Q

What is the ideal fluid restriction for peritoneal dialysis patients

A

insensible losses (500mL) + urine output + UF from PD (pt should know)

33
Q

CKD long case presentation stage 1-3 side effects discussion

A

HTN, fluid overload, electrolytes

34
Q

CKD long case presentation stage 4/5 SE discussion

A

HTN, fluid overload, electrolytes, CKD-MBD, renal anaemia, acidosis (save uraemia for clinical status)

35
Q

CKD long case presentation current status/symptoms/targets

A

Symptoms - uraemia, cramps, restless legs, neuropathy
Problems on dialysis
Targets (BP)
Adherence (diet, fluid restriction, meds)

36
Q

CKD long case presentation exam

A

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
Q

Glucocorticoids mechanism of immune suppression

A

Dampens all pathways

38
Q

What immunosuppression dampens signal 2 (costimulation of IL-2)

A

Calcineurin inhibitors

39
Q

What immunosuppression dampens signal 3 (proliferation)

A

mTOR
mycophenolate
azathioprine

40
Q

Treatment of cell mediated acute rejection

A

Methylpred pulse + T-cell depleting

41
Q

Treatment of antibdy mediated acute rejection

A

Pulse methylpred
Plasma exchange
IVIG

sometimes T-cell depleting ab / rituximab

42
Q

What the routine timeline for surveillance biopsies in kidney rejection

A

3 and 12 months

43
Q

What are factors for prevention of chronic rejection

A

Adherence
Absorption
Monitoring drug levels

44
Q

Approach to risk of rejection

A

Baseline and present renal function
HLA mismatch
DSAs (sensitising events in hx)
Previous renal biopsies

45
Q

What level of BK viral load indicates risk of BK nephropathy

A

10,000 copies/mL

46
Q

How to diagnose BK nephropathy

A

Renal biopsy

SV40 staining positive

47
Q

How to treat BK nephropathy

A

Reduce immunosuppression

IVIG

48
Q

Mechanisms of CNI toxicity

A

Acute:

  • vasoconstriction
  • reversible
  • high drug levels

Chronic:

  • tubulointerstitial and glomerular scarring
  • 100% of renal allografts at 10 years
49
Q

Approach to chronic allograft nephropathy

A 
Accumulation of immune and non immune injury
Pre transplant health
Rejection
CNI toxicity
BK nephropathy
Disease recurrence
AKI any cause
50
Q

What are cyclosplorin specific SE

A 
Gingival hyperplasia
Hypertrichosis
Hyepruricaemia
Dyslipidaemia
Hypertension
51
Q

What immunosuppression is teratogenic

A

Mycophenolate

52
Q

Causes of mortality post transplant

A

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
Q

Immunosuppression antimicrobials post transplant

A 
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
Q

Side effect of valganciclovir

A

leucopenia

55
Q

Renal transplant examination

A

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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