Renal Flashcards

Question 1

Q

Ongoing management of ESRF on peritoneal dialysis?

Answer

A

Goals

Maintain target weight & prevent fluid overload
Treat complications of CKD
Prevent dialysis-related complications
Transplantation consideration (if appropriate)

Maintain IBW & prevent hypervolaemia

I’d regularly monitor…
- Weight diary (IBW, current), residual urine output, volume status
- Adherence to FR (<2L, but sometimes not needed if has residual function), Low salt (<2g/d) diet
- Low K, Low Phosphate diet, involve dietician for dietary education
Check adherence with dialysis prescription
- Duration of overnight dwell
- Duration of drain
In case of fluid overload
- If residual function: FR, SR + Furosemide (up to 500mg TDS) to increase urine output
- Consider Icodextrin dialysate or Additional exchange - under guidance of nephrologist

Treat complications of ESRF

A: EPO, iron supplements (target Hb 100, ferritin >100, tSAT >20%), sodium Bicarbonate (titrate to Bicarb >22), watch fluid status
B (metabolic bone disease): monitor (Ca, PO4, Vit-D, PTH, Ca-PO4 product). Aim PO4 1.13-1.78.
- Phosphate binders (→ reduces PTH secretion)
  - I’d prefer to avoid calcium containing binders (e.g. calcium carbonate) as they are associated with increased mortality compared with calcium-free products & can be associated with hypercalcemia
  - Sevelamer or Lanthanum
- Calcitriol (as kidney can’t synthesize,)
- Calcimimetics (cinacalcet) - also suppresses PTH secretion
- Consider parathyroidectomy if severely elevated (e.g. >800)
C (cardiovascular RF Mx)
- target BP <130/80, LDL <2, Chol <4, HBA1C
- Screen ECG, stress test if symptomatic
- Weight reduction, exercise
D (RLS, neuropathies)
- RLS: iron supplementation, pregabalin, pramipexol
E (electrolyte) - monitor K, acid/base balance, resonium

Prevent dialysis-related complications

Monitor
- Tenkoff catheter malfunction, displacement, cellulitis
- Peritonitis - MCS, IP cephalosporins, vanc, gent
- Peritoneal membrane failure

Discuss transplantation if patient appropriate candidate.

Finally I’d make sure that patient is coping well with the dialysis.

Question 2

Q

Ongoing management of ESRF on Haemodialysis?

Answer

A

Goals

Maintain target weight & prevent fluid overload
Treat complications of CKD
Prevent dialysis-related complications
Transplantation consideration (if appropriate)

Maintain IBW & prevent hypervolemia

I’d regularly monitor…
- Weight diary (IBW, current weight), residual urine output, fluid status
- Adherence to FR, Low salt (<2g/d) diet
- Low K, Low Phosphate diet, involve dietician for dietary education
Check dialysis adequacy
- Ultrafiltration requirement per session
- HD stability - ask patient for home dialysis record?
- URR
- Kt/v
In case of fluid overload
- FR, SR + if residual function - Furosemide (up to 500mg TDS) to increase urine output
- Increase the duration of HD as tolerated, as per renal (increase time, or frequency)

Treat complications of ESRF

A: EPO, iron supplements (target Hb 100, ferritin >200, tSAT >20%), sodium Bicarbonate (titrate to Bicarb >22), watch fluid status
B (metabolic bone disease): monitor (Ca, PO4, Vit-D, PTH, Ca-PO4 product). Aim PO4 1.13-1.78. Phosphate binders (→ reduces PTH secretion)
- I’d prefer to avoid calcium containing binders (e.g. calcium carbonate) as they are associated with increased mortality compared with calcium-free products & can be associated with hypercalcemia
- Sevelamer or Lanthanum
- Calcitriol (as kidney can’t synthesize,)
- Calcimimetics (cinacalcet) - also suppresses PTH secretion
- Consider parathyroidectomy if severely elevated (e.g. >800)
C (cardiovascular RF Mx)
- target BP <130/80, LDL <2, Chol <4, HBA1C
- Screen ECG, stress test if symptomatic
- Weight reduction, exercise
D (RLS, neuropathies)
- RLS: iron supplementation, pregabalin, pramipexol
E (electrolyte) - monitor K, acid/base balance, resonium

Prevent dialysis-related complications

Monitor
- Access site: AV or graft fistula, vascath - thrills
- Thrombosis, stenosis, infection, vascular steal syndrome
- Bacteraemia, IE
- Bleeding
- Painful joints - suspect Amyloid

Discuss transplantation if patient appropriate candidate.

Finally I’d make sure that patient is coping well with the dialysis.

Question 3

Q

What side effects of medications would you ask for in renal transplant patients? (6, except for steroid complications)

Answer

A

MMMINS

Infection**
Metabolic - diabetes, OP, HTN, dyslipidemia, AVN
Malignancy - lymphoma, solid tumours, skin Ca
Macrovascular disease - IHD, Stroke, PVD (risk remains higher)
Nephrotoxicity
Specifics: Hirsuitism/Gingival [Cyclosporin], BM/GI [MMF], wound healing [mTOR]

Question 4

Q

Investigation and Management of worsening renal function in Renal transplant patients?

Answer

A

DDx includes (be specific to patient)…

Pre-renal
- Hypovolemia: sepsis, cardiac failure, bleeding, liver failure, RAS
Intra-renal
- Nephrotoxicity (CNI, mTOR) - drug induced
- Rejection
- Recurrence
- BK nephropathy
- CMV nephritis
- Pyelonephritis
Post-renal
- Obstructive uropathy

To investigate this further:

Routine bloods: FBC (anaemia, infection), EUC (trend), LFT, CRP (infection)
Special bloods: Drug levels e.g. tacrolimus troph, cyclosporin levels, Virology: BK PCR, CMV serology & PCR. Disease bloods - e.g. C3/4, dsDNA for lupus
Urine: ACR, PCR looking for proteinuria, wcc/rbc casts/blood (nephritis), decoy cells (BK)
Imagings: USS + doppler (obstruction, RAS), CTKUB
Kidney Biopsy

Question 5

Q

Ongoing management of Renal Transplantation

Answer

A

Goals:

Preserve graft function
Mx complications of immunosuppressants
Mx complications of CKD

Confirm Dx & Assess current function

EUC trend, UACR/UPCR, BP trend
Review renal biopsy

Address each goal

Graft function:
- Ix: 3-6 monthly EUCs, UPCR/UACR, drug levels, assess for volume status, graft tenderness, urine output
- Mx - if Cr worsens
  - Rule out hypovolemia, infection, drug induced toxicity, avoid nephrotoxins
  - Drug levels - adjust if troph too high
  - Rule out CMV nephritis & BK nephropathy
  - Consider kidney biopsy if no other causes found: ?rejection vs. recurrence
  - If CAN: Consider modifying ImmSx as per renal
Immunosuppression side effects
- Ix
  - 3 monthly HBA1C, Lipid profile, BP, DEXA 1-2 yearly for Metabolic
  - Age-appropriate Malignancy surveillance (skin, FOBT, MMG, PSA), FBC + monitor for B-symptoms, splenomegaly, LN for PTLD
- Mx
  - Infection prophylaxis: Bactrim, Valganciclovir, Fluconazole
  - Vaccination, a high index of suspicion for infection & aggressive treatment
  - Optimise CV risk factors: aim BP <130/80, LDL <2, Chol <4 diet, exercise, weight, pharmacological measures
CKD
- Ix
  - FBC (anaemia), EUC for K+ and Bicarb (acidosis), CMP for CPP
  - Renal bone disease: Ca, Phos, Vit D, PTH, ALP
  - RLS: iron levels, clinical exam for PN
- Mx
  - A: EPO, iron supplements (target Hb 100, ferritin >100, tSAT >20%), sodium Bicarbonate (titrate to Bicarb >22), Resonium
  - B (metabolic bone disease):
    - Low phosphate diet
    - Phosphate binders (→ reduces PTH secretion)
    - Calcitriol (as kidney can’t synthesize,)
    - Calcimimetics (cinacalcet) - also suppresses PTH secretion
    - Consider parathyroidectomy if severely elevated (e.g. >800)
  - RLS: iron supplementation, pregabalin, pramipexol

Question 6

Q

AV fistula management & preventing complications

Answer

A

If the patient has recurrent infection:

consider “rope-ladder” technique (rotating cannulation site) rather than “button-hole” (same site for cannulation), which has lower risk of infection. However it is associated with increased bleeding risk (especially if anticoagulated)
- Using Mupirocin cream (Bactroban) reduces the risk of S. Aureus bacteremia associated with Button hole technique
Check patient’s technique - skin should be cleaned with chlorhexidine
Make sure patient keeps the site clean, avoid wearing clothing/jewelry or any activities that may restrict the flow (hence risk of thrombosis)
Teach patient how to examine fistula