r e n a l 2

Question 1

what are the different types of RRT

Answer 1

peritoneal dialysis
haemodialysis
transplantation

Question 2

how does P.D work

Answer 2

acting as the dialysis membrane.
• Solutes (electrolytes, urea, creatinine) move from
the patient’s blood, across the peritoneal membrane, down the concentration gradient into the dialysate fluid.
• Osmotic gradient is created by high concentration of glucose (occasionally amino acid or glucose polymer solutions are used) in the dialysate fluid, which removes water from the patient.

Question 3

what are the advantages of P.D

Answer 3

Quality of life
• It is often an excellent first choice for patients starting dialysis, particularly when they still have some residual native renal function
• PD regimes are designed on a much more individualised basis than patients on HD.

Question 4

what are the disadvantages of P.D

Answer 4

Patients need to be able to manage technical
aspects of dialysis
• Unsuitable in patients with stoma/previous surgery
• Risk of infection (PD peritonitis)
• Complications – drainage problems, malposition,
leaks, herniae, hydrothorax, long term use
associated with encapsulating peritoneal sclerosis

Question 5

what are the different forms of P.D and the advantages of each

Answer 5

automated P.D = performed at night.
• 10-12L usually exchanged, over 8-10 hours.
• Lifestyle advantages – Leaves the daytime free

continuous ambulatory P.D - consisting of 4-5 dialysis exchanges per day (usually 2 litres each)
• Exchanges are performed at regular intervals throughout the day, with a long overnight dwell

assisted automated P.D
Trained healthcare assistants visit the patient’s home to help with setting up APD.

Question 6

what are is haemodialysis used for

Answer 6

Can be used for AKI and ESRF (temporary dialysis vs. permanent)

Question 7

how does haemodialsysis work

Answer 7

dialysis machine pumps blood from the patient, through disposable tubing, through a dialyser, or artificial kidney, and back into the patient. Waste solute, salt and excess fluid is removed from the blood as it passes through the dialyser.

Question 8

what are the advantages of haemodialysis

Answer 8

Efficient form of dialysis

• Unit-based – plenty of support from staff

Question 9

what are the disadvantages/ complications of haemodialysis

Answer 9

Dialysis access needs to be secured
• Infection/Bacteraemia
• Haemodynamic instability
• Reactions to dialysers
• Haematomas/risk of bleeding
• Muscle cramps
• Anaemia due to clotted lines/Haemolysis • AVF steal syndrome
• SVCO from central lines

Question 10

what are the different types of H.D and their adv or disadv

Answer 10

Home HD – offer training at home for more frequent HD

Nocturnal HD – Overnight slow, long HD

CRRT – continuous renal replacement therapy mainly used in acute setting (ITU/HDU)

Question 11

what are the adv of renal transplantation

Answer 11

Near normal lifestyle

• Better mortality/morbidity

Question 12

what are the disadvantages of renal transplant

Answer 12

Criteria to meet suitability to safely undergo operation
• Compliance with medication lifelong
• Risk of rejection
• Risk of malignancies over time
• Risk of infection (on immunosuppression) • Long waiting times for cadaveric organ

Question 13

when is conservative management offered rather than RRT

Answer 13

Decision made after discussion with patient and family members – often after multiple clinic visits and after patient is fully informed of risks & benefits of each mode of therapy

Evidence suggests that if
• Age >80 OR
• WHO performance score of 3 or more
...then RRT offers no survival benefit
Often these patients may be unsuitable for or choose to not have invasive therapy such as PD/HD/Transplantation

Question 14

what is the active conservative management of ESRF

Answer 14

• Symptom control to enhance quality of life
• Respect patients preferred place of care
• Advanced care plan
• MDT approach
• Support system for patient and family

Question 15

describe the long term care of tx patient

Answer 15

imes a month, after 6 months it happens less often
• Monitor GFR, CNI levels, proteinuria, Ca, phosphate and PTH, lipids and glucose
• Screen for infections (common and opportunistic) • Vaccination (except live or live attenuated viral
vaccines)
• Monitor and control cardiovascular disease, bone
and mineral metabolism disease
• Screen for malignancies as patients are three
times more likely to have any cancer
• Annual skin checks for skin cancers
• Contraception is obligatory in the first year, counsel about pregnancy one year after
• Mortality is related to: cardiovascular disease, infections and malignancies

Question 16

what are the important germs to consider in tx patients

Answer 16

Important germs to consider: CMV, hepatitis B,
Herpes simplex virus, Varicella zoster, EBV, BK; Aspergilllus, Pneumocystis jirovecii, Listeria, Mycobacterium tuberculosis, Toxoplasma gondii
• Within the first year, some patients can develop new-onset diabetes after transplant (NODAT); important to remember personal risk factors and new factors, such as medications and a new gluconeogenic kidney.

Question 17

what is the triad for nephrotic syndrome

Answer 17

Oedema
 Albumin <30
 Urine PCR >350 (more than 3.5 grams of protein in 24 hours)
o Hypercholesteraemia

Question 18

what are the complications of nephrotic syndrome

Answer 18

 Higher risk of Infection
 Venous thromboembolism
 Progression of CKD
 Hypertension
 Hyperlipidaemia

Question 19

what are the causes of nephrotic syndrome

Answer 19

Minimal Change Disease – most common form of GN in children
 Focal Segmental Glomerulosclerosis – Idiopathic or secondary to infection, malignancy, drugs etc.
 Membranous Nephropathy – Idiopathic or secondary to infection, malignancy, drugs etc.
 Membranoproliferative Glomerulonephritis (more commonly presents as nephritic syndrome)
 Amyloidosis/Myeloma/Diabetes may have nephrotic range proteinuria but not necessarily other nephrotic features

Question 20

describe the presentation of nephritic syndrome

Answer 20

AKI (sometimes GFR can drop drastically)
 On urine dipstick: blood +/- and/or protein+/- Mild to moderate oedema
 Proteinura <3.5g/24 hours
 Hypertension
 Sometimes visible haematuria

Question 21

describe the management of GN

Answer 21

Supportive therapy
 If suspect GN – discuss with Renal team
 MDT approach depending on underlying diagnosis
 ACEi/ARB for proteinuria
 Control BP
 Salt and water restriction if volume overloaded
 Diuretics for fluid overload
 If hypoalbuminaemic <20g/dl then higher risk for VTE – consider therapeutic LMWH
 Statins for hypercholesterolaemia
Immunosuppressive therapy:
 Specific to cause of GN – decided by Renal team (+/- Respiratory / Rheumatology teams if lung or systemic
involvement )
 Oral Corticosteroids, IV pulsed methylprednisolone, Cyclophosphamide, Tacrolimus, Ciclosporin, Rituximab, MMF,
Azathioprine Invasive therapy
 Renal replacement therapy/haemodialysis for those in severe AKI or ESRF  Plasma exchange for AAV (with lung involvement), anti-GBM

Question 22

describe the mantainbce fluid requirements for water, K, Na CL and glucose

Answer 22

25-30 ml/kg/day of water

approximately 1 mmol/kg/day of potassium, sodium and chloride

approximately 50-100 g/day of glucose to limit starvation ketosis