Microvascular complications and the kidney. Diabetic nephropathy. When to start dialysis. Flashcards
What are the features of diabetic nephropathy?
Hypertension.
Progressively increasing proteinuria.
Progressively deteriorating kidney function.
Classic histological features.
What are the histological features of diabetic nephropathy?
Glomerular changes: mesangial expansion, basement membrane thickening, glomerulosclerosis.
What are the clinical features of diabetic nephropathy?
Progressive proteinuria.
Increased BP.
Deranged renal function.
What is the normal range for proteinuria?
<30mg/24hr.
What are the strategies for intervention in diabetic nephropathy?
Diabetic control.
Blood pressure control.
Inhibition of the activity of RAS system: beneficial effect of ACEi.
Smoking cessation.
Which of the following are features of diabetic nephropathy?
a) affects all patients with diabetes over time
b) associated with decreased BP
c) progressively increasing proteinuria
d) unrelated to glycaemic control
e) associated with a low risk of cardiovascular events
Progressively increasing proteinuria.
Regarding ACE inhibitors in patients with diabetes:
a) ACE inhibitors cause an improvement in the creatinine within days of starting
b) ACE inhibitors cause an increase (worsening) of the creatinine within days of starting
c) ACE inhibitors increase microalbuminuria
ACE inhibitors cause an increase (worsening) of the creatinine within days of starting
Regarding ACE inhibitors in patients with diabetes:
a) ACE inhibitors are useful in patients with diabetes and resultant renal artery stenosis
b) ACE inhibitors increase microalbumiuria
c) ACE inhibitors prevent end stage renal failure
d) ACE inhibitors cause hypokalaemia
ACE inhibitors cause hypokalaemia.
What happens in renal failure?
Electrolyte imbalance: hyperkalaemia, hyponatraemia.
Acidosis.
Fluid retention.
Retention of waste products: small molecules, e.g. urea, creatinine, urate; phosphate; middle molecule, e.g. peptides, beta 2 microglobulin.
Secretory failure: erythropoietin, 1,25 vitamin D.
Symptoms: tiredness, lethargy, shortness of breath, oedema, pruritis, nocturne, feeling cold, twitching, poor appetite, nausea, loss of/nasty taste, weight loss.
Anaemia- exacerbates tiredness.
Renal bone disease- aches and pains, pruritis.
What are the symptoms of renal failure?
Tiredness, lethargy.
Shortness of breath, oedema.
Pruritis, nocturne, feeling cold, twitching.
Poor appetite, nausea, loss of/nasty taste, weight loss.
Anaemia- exacerbates tiredness.
Renal bone disease- aches and pains, pruritis.
What are the implications of renal failure with no renal replacement treatment?
Hyperkalaemia- arrhythmias, cardiac arrest. Pulmonary oedema. Nausea, vomiting. Malnutrition/ cachexia. Fits. Increasing coma. Death.
What are the different renal replacement treatments?
Dialysis: - haemodialysis, predominantly hospital-based, but can be done at home - peritoneal dialysis, home treatment. Transplantation. None of these are cures.
What are the aims of renal replacement treatment?
Correct electrolyte and acid-base status. Remove waste products. Restore fluid balance. Improve symptoms. Maintain quality of life for patient.
When is renal replacement treatment started?
eGFR <10ml/min and benefits outweigh risks.
eGFR <6ml/min and no reversible features; life-threatening complications.
What are the benefits of dialysis?
Improve uraemic symptoms: tiredness, nausea, pruritis.
Correct fluid balance: less SOB and oedema.
Avoid life-threatening events: severe acidosis, severe hyperkalaemia, pulmonary oedema resistant to diuretics.
What are the risks of dialysis?
Dialysis related complications: infection (HD and PD); hypotension, arrhythmias (HD); access-related (HD and PD).
Adverse effects on quality of life: work, family, travel.
Dialysis does not treat: lack of erythropoietin (anaemia); lack of 1,25 vitamin D (hyperparathyroidism, renal bone disease); other disease and comorbidities: SLE; diabetes; vascular disease.
Haemodialysis vs. peritoneal dialysis.
Haemodialysis: hospital based treatment, 3x a week, 4hrs only but time to recover plus transport; vascular access needed (catheter or A-V fistula); quality of life (done for you and does not invade home, limits travel, work, loss of independence).
Peritoneal dialysis: home based treatment, daily and continuous, less haemodynamic stress, limited by access to peritoneum and ability to do technique; quality of life (maintains independence, easier to travel, work, avoids swings of HD, less dietary and fluid restrictions).
What are the benefits of renal transplantation?
Better renal replacement.
Improvement in metabolic disorders (anaemia, renal bone disease).
Costs less long-term.
Prolonged survival.
Quality of life: avoids disadvantages of HD/PD; much easier to travel, work, maintain independence.
What are the risks of renal transplantation?
Older and sicker patients not eligible (comorbidities).
Immunosuppression: increased infection, increased malignancy.
Not a cure: surgical complications, hospital visits particularly frequent at start.
Often worse off if/when transplant fails.
What are the important outcomes of dialysis for patients/caregivers?
Ability to travel Dialysis adequacy Dialysis-free time Fatigue Anaemia Blood pressure Impact on family/friends Washed out after dialysis
What are the important outcomes of dialysis for medical professionals?
Vascular access problems Cardiovascular disease Death/mortality Drop in blood pressure Hospitalisation Fatigue Infection/immunity Ability to work
From a patient perspective, what is the point of starting dialysis?
Relief of symptoms Achieve quality of life goals: social and family interactions, physical activity (travel, work, exercise, self-care), mental activity (work, hobbies) Extend life (with good quality) Avoid complications of treatment
What is the point of starting dialysis from the physician’s perspective?
Sick patient- have to do something
Meets criteria for starting dialysis
Belief that dialysis will benefit patient
Spaces available in HD unit- need filling, particularly important in private sector
Patient may not do well, but let’s give dialysis a try- easier than long conversation about prognosis, end of life wishes, etc.
Patient autonomy: dialysis or not
Patients must be given realistic and accurate information to enable them to make appropriate decision.
Patients cannot demand treatment if not appropriate.
Not relevant if patient lacks capacity.
