Renal Flashcards
Cx of CKD
HTN
Anaemia
Poor growth
Metabolic bone disease (renal osteodystrophy or renal rickets
Electrolyte imbalance
Acidosis
Fluid balance
Uraemia
Define the stages of CKD
1: GFR >90 (normal) with some evidence of kidney damage
2: GFR 60-90
3: GFR 30-60
4: GFR 15-30
5: GFR <15 (requiring dialysis or transplant)
- ESRF: defined as when medical mgmt is no longer working and RRT is necessary
Stages 1-3: focus is on monitoring and reducing disease progression (control HTN, exclude UTIs and obstructions, ACEi/ARBs to reduce proteinuria)
Stage 4: focus is treating complications and preparing for dialysis or transplant
Stage 5: focus is RRT, awaiting transplant
Management of HTN in CKD
- Fluid and salt restriction
- Ace inhibitors first line
- Ca channel blockers second line
- Diuretics
Mgmt of anaemia in CKD
- Iron supplementation (PO if pre RRT, IV if on RRT)
- Epo injections
- transfuse if Hb <60 to avoid cardiac decompensation
mgmt of poor growth in CKD
- Endo: recombinant human Growth hormone if height <3rd centile
- Nutrition: Dietician, NG or PEG, Special feeds (low Ph, high calorie; low protein only if ESRF to reduce Ur burden)
- Minimise steroids
- Control acidosis
- Correct anaemia
- Manage bone disease
- Adequate salt intake
Mgmt of bone disease in CKD
- Unable to excrete Ph, nor make 1,25 hydroxyvitamin D (calcitriol) -> secondary hyperparathyroidism
- Sx: bone pain, deformities (bowed legs or knock knees), dental issues
- Monitor: serum Ca, Ph, ALP, PTH, calcitriol, bone X-rays (hips, knees, ankles and bone age - wrist), DEXA
- Mx: low Ph diet and Ph binder (ca carbonate), Ca carbonate (ca supp), calcitriol
- Monitor treatment with serum ALP nad PTH levels
Management of hyperkalaemia in CKD
- HyperK: dietary restriction + acute mgmt (salbutamol, Ca gluconate, sodium bicarbonate, insulin and dextrose, resonium, dialysis)
Management of acidosis in CKD
- From retaining H+ and wasting bicarb
- Oral bicarb supps or RRT
Management of fluid balance in CKD
- Oliguric -> Oedema and HTN:
- Fluid restriction
- low Na diet
- ACE inhibitors or ARBs
- diuretics
- dialysis
- OR Na and water wasting (usually congenital renal disease):
- Na supplementation
- high fluid intake
- IV fluids if unwell w vomiting or diarrhoeal illness
- Monitor urinary Na excretion and weight
Forms of dialysis and main cx
Peritoneal dialysis
- can be done at home, daily with automated machine
- uses tenckoff catheter (abdominal site)
- Continuous overnight
- Intermittent during day (3-4 cycles during the day)
- Cx: peritonitis (abdominal pain, cloudy fluid -> send for MCS), catheter infections, catheter blockage
Haemodialysis
- has to be done in hospital 3-4x per week
- Vas-cath or perma-cath (both double lumen) or AV fistula
- Cx: cath infections and blockage
- Need play therapist and in hospital school teacher!
Major risk factor for graft failure in teenagers
Non compliance w immunosuppressive medication
Cx of renal transplant
- SEs of immunosuppressant medications
- Steroids
- Mycophenolate: myelosuppression and risk of infection, malignancy (lymphoma, leukaemia), GI (diarrhoea, GI bleeding, perforation)
- Azathioprine
- Tacrolimus (SE include nephrotoxicity, neurotixicty, infection, lymphoproliferative disease)
- Monoclonal Abs: Nausea, vomiting, allergy, headache
2 . Immunosuppression and risk of opportunistic infections
- Need to be on CMV prophylaxis with valganciclovir
- Risk of malignancy later in life (lymphoma nad skin cancers)
- Graft rejection (Acute or chronic)
- HTN
- Hypercholesterolaemia
- CV disease (long term effect of HTN, hypercholesterolaemia)
- Disease recurrence (esp FSGS, MPGN, HSP, iGA nephrpopathy, HUS, SLE)
- Vascular thrombosis
Signs of graft rejection
Rising Creatinine
Leukocytosis
Graft tenderness
Fever
Confirm on renal bx
Mx - IV steroids +/- biologics
main causes of nephrotic syndrome in childhood
Minimal change disease - most start out steroid responsive but have relapsing/remitting course and may become steroid resistant
FSGS - often steroid non responsive, req immunotherapies
Mesangial proliferative GN
main causes of nephrotic syndrome in childhood
Minimal change disease - most start out steroid responsive but have relapsing/remitting course and may become steroid resistant
FSGS - often steroid non responsive, req immunotherapies
Mesangial proliferative GN
