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Clinical exam - long cases > Renal > Flashcards

Renal Flashcards

1
Q

What associated features need to be examined for in polycystic kidneys?

A 
Hepatic and splenic cysts
HTN
Anaemia or polycythaemia
U/A: blood from ruptured cysts
Mitral prolapse
CNIII palsy (pComm aneurysm)
Abdominal hernias
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2
Q

What 4 criteria should suggest renal allograft rejection following renal transplant?

A
  • Cr rise > 25% from baseline, or higher than expected
  • Worsening HTN
  • Proteinuria > 1g/d
  • Plasma donor-derived cell-free DNA > 1%
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3
Q

How are the following patient groups treated for antibody-mediated rejection?

  • Rejection before 1 year
  • Rejection after 1 year
A

Before 1 year: Prednisone, plasmapheresis, IVIG +/- rituximab

After 1 year: Prednisone, IVIG +/- rituximab

All improve short term but not long term outcomes

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4
Q

At the time of renal transplant, what is the recommended induction immunosuppression?

A
  • First line: Basiliximab

- High risk: rATG

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5
Q

What should be commenced at the time of renal transplant?

A
  • Tacrolimus
  • Mycophenolate
  • In low immunological risk, steroids may be ceased within 1st week
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6
Q

What strategies may be used to reduce drug costs?

A
  • Limiting biologics to those who are high risk for rejection
  • Ketoconazole or a non-dihydropyridine CCB (eg verapamil) to reduce CNI doses
  • Using AZA rather than mycophenolate
  • Using prednisone long term
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7
Q

What drug monitoring should be recommended in renal transplant?

A

CNIs 12-hour trough

  • Initially until levels are within target range
  • Following drug dose adjustment or pt status may affect blood levels
  • Decline in renal function suggesting nephrotoxicity or rejection

Mycophenolate

  • Weekly until stable for 4 weeks then
  • Fortnightly for 2 months then
  • Monthly
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8
Q

How should acute rejection be treated?

A

Acute cellular rejection:

  • Steroids
  • OKT3 (muromonab) for those who do not respond to steroids. Anti-CD3.

Antibody-mediated rejection:

  • May employ steroids
  • Plasma exchange
  • IVIG
  • Anti-CD20
  • OKT3 (muromonab)
  • Add MMF, or change AZA to MMF
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9
Q

How should chronic allograft injury be treated?

A
  • Reduce or replace CNI if CNI toxicity occurs (biopsy)

- if eGFR>40 and total protein excretion < 500mg per gram of Cr, change CNI to mTORi

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10
Q

How should recurrent kidney disease be treated after renal transplant?

A
  • FSGS or minimal change => plasmapheresis
  • ANCA-associated or anti-GBM => high dose steroids, cyclophosphamide
  • Hyperoxaluria => pyridoxine, high calcium/low oxalate diet
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11
Q

What are the vaccination recommendations in kidney transplants?

A
  • No vaccinations within 6 months post transplant, except fluvax, which may be given after 1 month post transplant
  • No live vaccinations
  • HBV vaccination (ideally pre-transplant) and HBsAb titres 6-12 weeks later
  • Annual HBsAb titres
  • Revaccination if HBsAb titre falls below 10
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12
Q

What does KDIGO say about viral Mx post renal transplant?

A

BK virus

  • Quantitative plasma NAT for the first year 1-3monthly
  • Check whenever unexplained rise in Cr or after acute rejection episode
  • Reduce immunosuppression if BK NAT > 10,000

CMV

  • Valganciclovir for at least 3months post transplant and at least 6 weeks after T-cell depleting mAb
  • In those with CMV disease => weekly NAT monitoring
  • Serious CMV infection => IV gangiclovir
  • Reduce immunosuppressives if CMV infection is life-threatening

EBV

  • Monitor high risk pts (D+R-) with EBV NAT for the first year post- transplant and after acute rejection
  • In active disease, reduce or cease immunosuppression

Hep C
- Monitor ALT 3-6 monthly + annual US for HCC

Hep B

  • HBsAg pos => prophylaxis with tenofovir or entecavir
  • During antiviral Rx, measure HBV DNA and ALT every 3 months

HIV
- Screen, if not already done

PCP
- Bactrim prophylaxis for 3-6 months post transplant

TB
- Consider substituting rifabutin for rifampicin to minimise interactions

UTI
- Bactrim prophylaxis for 6 months post transplant

Candida
- Nystatin prophylaxis for 1-3 months post transplant

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13
Q

How should CV risk factors be optimised in renal transplant patients?

A

NODAT

  • HbA1c annually
  • Monitor for hyperglycaemia if CNI, mTORi or steroid doses increase
  • Target HbA1c 7-7.5%
  • Consider aspirin 100mg daily in diabetics

HTN

  • Target BP < 130/80
  • ACEI if proteinuria>1g daily

Lipids
- Treat if elevated

Smoking
- Assist cessation

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14
Q

What are the recommendations re: skin cancer monitoring in renal transplant?

A
  • Annual skin checks

- Consider acitretin in those with a Hx of skin cancer

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15
Q

How should those with Kaposi sarcoma and renal transplant be treated?

A

mTORi rather than CNI

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16
Q

What are the aspects of monitoring necessary in kidney transplants?

A
  • Acute and chronic rejection
  • Kidney disease recurrence (eg FSGS)

Infection

  • Vaccination
  • Viruses: BK, CMV, EBV
  • Hep B treatment if HBsAg pos
  • HIV screening
  • PJP

Metabolic and CVS

  • NODAT
  • Hyperuricaemia and gout
  • Bone disease
  • CV risk factors

Drug side effects

  • Skin cancers
  • Immunosuppresive Rx levels
  • Monitor FBC. Treat erythrocytosis with ACEIs

Fertility
- Stop mycophenolate and mTORi before conception

17
Q

What is the primary biomarker used to differentiate Ab-mediated rejection from other rejection?

A

Donor-derived cell-free DNA (dd-cfDNA)

18
Q

What are the markers of complement fixation used to assess for antibody-mediated rejection?

A

C1q or C3d DSAs, or C4d staining.

In 50% of pts C4d staining is negative => Dx on biopsy – increased expression of gene transcripts or classifiers.

19
Q

What are the consequences of donor-specific antibodies?

A

Increased risk of antibody-mediated rejection
More severe Ab-mediated injury
Overexpression of allograft genes responsible

20
Q

What questions need to be asked about renal transplant?

A 
Cause of renal failure
Source of transplant
HLA and ABO compatibility
CMV status
Rejection Hx (fever, swelling, tenderness)
Biopsies
Immunosuppression
- Cyclosporin: hirsutism, tremor, renal impairment, hyperkalaemia, hypomagnesaemia, gout, HTN, gingival hypertrophy, haematological malignancy
- Infections
- Malignancy
IHD, PVD
21
Q

What are the dietary recommendations in CKD?

A

Normal diet if eGFR>60

Protein restriction
- Not dialysis + not nephrotic => restriction to 0.6-0.8g/kg

Sodium

  • HTN, volume overload or proteinuria => 2g or less Na daily
  • None of the above => 2.3g or less Na daily

Potassium
- Stage III or IV => restrict to 2-4g K daily

Calcium 800-1000mg daily

Phosphurus < 1g daily in dialysis pts

22
Q

What are the different forms of renal osteodystrophy (CKD-MBD)?

A
  1. Osteitis fibrosa cystica - caused by secondary hyperparathyroidism
  2. Adynamic bone disease - caused by excessive parathyroid gland suppression
  3. Osteomalacia - low bone turnover in combination with abnormal mineralisation
23
Q

What are the main aspects of CKD management?

A

Diet
- Protein, K, Na, Ca restriction

Anaemia

  • Start Erythropoiesis Stimulating Agent when Hb < 100
  • Aim Tsat ≥ 30% and Ferritin ≥ 500 in anaemia
  • If not anaemic, aim Tsat ≥ 20% and Ferritin ≥ 100

CKD-MBD
- Commence calcitriol 0.25mcg 3 times weekly if PTH > 2.3-3.0 x ULN

24
Q

When should planning for dialysis be commenced?

When should dialysis commence?

A

Vascular access planning at eGFR 20

Dialysis at eGFR 7-10

25
Q

What conditions are associated with IgA nephropathy?

A

Coeliac
Chronic liver disease
IBD
HIV

26
Q

What are the causes of membranoproliferative GN?

A 
Hep C
Indolent infections (malaria, syphilis)
Autoimmune diseases
Essential cryoglobulinaemia
Malignancies
Drugs - NSAIDs, penicillamine, anti-TNF drugs
27
Q

What are the secondary causes of membranous GN?

A 
SLE
Hep B
Hep C (rare)
Anti-TNF / Penicilliamine / NSAIDs
Malignancy
HSCT / GVHD
Sarcoidosis
28
Q

What are the causes of FSGS?

A

HIV
Morbid obesity
Reflux nephropathy
Heroin use

29
Q

What are the causes of crescentic (rapidly progressive) GN?

A

Anti-GBM disease
Immune complex: IgA nephropathy, postinfectious GN, lupus nephritis, cryoglobulinaemia
Pauci-immune: GPA, MPA

30
Q

Which medications are associated with ANCA-positive disease?

A

Propylthiouracil
Hydralazine
Allopurinol
Penicillamine

31
Q

What are the extrarenal manifestations of ADPKD?

A 
Hepatic cysts
Pancreatic cysts
Splenic cysts
Thyroid cysts
Seminal vesicle cysts
Intracranial aneurysms
HTN
Diverticular disease
Hernias
32
Q

What are the complications of CKD?

A 
HTN
CCF
Fluid overload
Anaemia
Uraemia
- Peripheral neuropathy
- Pruritus
- Pericarditis
- Cognitive impairment
Bone disease 
Gout and pseudogout
Peptic ulcers
Poor nutrition

Clinical exam - long cases (9 decks)

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