Microvascular complications and the kidney. Diabetic nephropathy. When to start dialysis.

Question 1

What are the features of diabetic nephropathy?

Answer 1

Hypertension.
Progressively increasing proteinuria.
Progressively deteriorating kidney function.
Classic histological features.

Question 2

What are the histological features of diabetic nephropathy?

Answer 2

Glomerular changes: mesangial expansion, basement membrane thickening, glomerulosclerosis.

Question 3

What are the clinical features of diabetic nephropathy?

Answer 3

Progressive proteinuria.
Increased BP.
Deranged renal function.

Question 4

What is the normal range for proteinuria?

Answer 4

<30mg/24hr.

Question 5

What are the strategies for intervention in diabetic nephropathy?

Answer 5

Diabetic control.
Blood pressure control.
Inhibition of the activity of RAS system: beneficial effect of ACEi.
Smoking cessation.

Question 6

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

Answer 6

Progressively increasing proteinuria.

Question 7

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

Answer 7

ACE inhibitors cause an increase (worsening) of the creatinine within days of starting

Question 8

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

Answer 8

ACE inhibitors cause hypokalaemia.

Question 9

What happens in renal failure?

Answer 9

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.

Question 10

What are the symptoms of renal failure?

Answer 10

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.

Question 11

What are the implications of renal failure with no renal replacement treatment?

Answer 11

Hyperkalaemia- arrhythmias, cardiac arrest.
Pulmonary oedema.
Nausea, vomiting.
Malnutrition/ cachexia.
Fits.
Increasing coma.
Death.

Question 12

What are the different renal replacement treatments?

Answer 12

Dialysis:
- haemodialysis, predominantly hospital-based, but can be done at home
- peritoneal dialysis, home treatment.
Transplantation.
None of these are cures.

Question 13

What are the aims of renal replacement treatment?

Answer 13

Correct electrolyte and acid-base status.
Remove waste products.
Restore fluid balance.
Improve symptoms.
Maintain quality of life for patient.

Question 14

When is renal replacement treatment started?

Answer 14

eGFR <10ml/min and benefits outweigh risks.

eGFR <6ml/min and no reversible features; life-threatening complications.

Question 15

What are the benefits of dialysis?

Answer 15

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.

Question 16

What are the risks of dialysis?

Answer 16

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.

Question 17

Haemodialysis vs. peritoneal dialysis.

Answer 17

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).

Question 18

What are the benefits of renal transplantation?

Answer 18

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.

Question 19

What are the risks of renal transplantation?

Answer 19

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.

Question 20

What are the important outcomes of dialysis for patients/caregivers?

Answer 20

Ability to travel
Dialysis adequacy
Dialysis-free time
Fatigue
Anaemia
Blood pressure
Impact on family/friends
Washed out after dialysis

Question 21

What are the important outcomes of dialysis for medical professionals?

Answer 21

Vascular access problems
Cardiovascular disease
Death/mortality
Drop in blood pressure
Hospitalisation
Fatigue
Infection/immunity
Ability to work

Question 22

From a patient perspective, what is the point of starting dialysis?

Answer 22

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

Question 23

What is the point of starting dialysis from the physician’s perspective?

Answer 23

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.

Question 24

Patient autonomy: dialysis or not

Answer 24

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.

Question 25

Beneficence: dialysis or not

Answer 25

Prolongs survival.
Improves quality of life.
Improves symptom burden.
Dialysis should benefit the patient.

Question 26

Avoid harm: dialysis or not

Answer 26

Dialysis should not harm the patient.
Shortens survival.
No improvement or worse quality of life.
Increases symptom burden.

Question 27

Justice: dialysis or not

Answer 27

Limited resources in all healthcare systems.
Dialysing patients who would not benefit leads to dialysis staff/machines not being available for patient who may benefit, and money/resources not being available for other healthcare needs.

Question 28

What is conservative care in ESRF?

Answer 28

Non-dialysis pathway chosen by patient after shared decision making with predialysis team.
Active management of anaemia with ESA and IV iron.
BP control- slow rate of decline and lower stroke risk.
Optimise fluid balance- avoid over and under hydration.
Symptom control, including pain.
Joint management with palliative care team at end of life phase.

Question 29

What is the UK definition of supportive care?

Answer 29

Care that helps patient and family to cope with condition and its treatment: from prediagnosis, through diagnosis and treatment, to cure, continuing illness or death, into bereavement.
Helps patient maximise benefits of treatment and to live as well as possible with effects of disease.
As important as diagnosis and treatment.

Question 30

What is palliative care?

Answer 30

Care which enables people with progressive and/or life threatening conditions or who are approaching the end of life to live according to their wishes and preferences wherever possible.

Question 31

How are the aims of supportive care achieved?

Answer 31

Communication with patient and family: patient and family expectations and wishes, symptoms and pain control, realistic prognosis.
Awareness of patient being near end of life.
Advance care planning.
Appropriate active interventions, e.g. antibiotics, dialysis, ventilation- and discussing withdrawal where appropriate- or not starting.

Question 32

At what stage should discussions be held with patients about prognosis?

a) When diabetes first diagnosed.
b) When complications such as kidney disease or ischaemic heart disease FIRST diagnosed.
c) When interventions required for complications, e.g. dialysis, heart surgery.
d) Wait until patient deteriorating and clinically at end of life.

Answer 32

When diabetes first diagnosed.

Question 33

What is the microalbuminuric range for proteinuria?

Answer 33

30-300mg/24hr.

Question 34

What is the asymptomatic range for proteinuria?

Answer 34

300-3000mg/24hr.

Question 35

What is the nephrotic range for proteinuria?

Answer 35

> 3000mg/24hr.