Renal II Flashcards

Question

What is the BP aim for patients with CKD? [1] What is the BP aim for patients with CKD & DM or ACR > 70? [1]

Answer 1

What is the BP aim for patients with CKD? [1] * **< 140/90** What is the BP aim for patients with CKD & DM or ACR > 70? [1] :**< 130/80**

Answer 2

* eGFR less than **30 mL/min/1.73 m2** * Urine **ACR** **more than 70 mg/mmol** * **proteinuria > 30 mg/mmol & haematuria** * **Accelerated** **progression** (a decrease in **eGFR of 25% or 15 mL/min**/1.73 m2 within 12 months) * **5-year risk of requiring dialysis over 5%** * **Uncontrolled hypertension** despite four or more antihypertensive

Answer 3

**Slow disease progression:** - **ACE inhibitors** (or angiotensin II receptor blockers) - **SGLT-2 inhibitors** (specifically dapagliflozin) **To reduce risk of complications:** - **Atorvastatin** **20mg** (prevents CV disease)

Answer 4

ACE inhibitors are offered to all patients with: * **Diabetes** plus a urine **ACR above 3 mg/mmol** * **Hypertension** plus a urine **ACR above 30 mg/mmol** * All patients with a **urine ACR above 70 mg/mmol** SGLT-2 Inhibitors Dapagliflozin is the SGLT-2 inhibitor licensed for CKD. It is offered to patients with: * **Diabetes plus a urine ACR above 30 mg/mmol**

Answer 5

**< 150mg/day**

Answer 6

**Gout**: due to inhibition of uric acid secretion

Answer 7

**Lithium**: have reduced excretion, so have increased levels occur **Digoxin toxicity increased**: due to diuretic associated hypokalaemia **Aminglycosides** can become more nephrotoxic

Answer 8

**Hypokalemia**. Most widely recognized, the first adverse effect of thiazide diuretics is hypokalemia. **Hyponatremia**. The MOA of thiazide diuretics is to decrease sodium reabsorption and therefore decreased fluid reabsorption; this directly causes decreased levels of circulating sodium. **Metabolic alkalosis**. Patients on thiazide diuretics may experience a hypokalemic metabolic alkalosis due to the increase in aldosterone-mediated K and H ions excretion in the intercalated cells of the CT. **Hypercalcemia**. By increasing calcium reabsorption from the luminal membrane into the interstitium in exchange for sodium, thiazides reduce urine calcium levels and increase blood calcium. However, if indicated, this effect of thiazide diuretics makes thiazides useful for nephrolithiasis and osteoporosis treatment. Decreased urinary calcium decreases stone development in the kidney, and increased blood calcium is beneficial for patients with osteoporosis and promotes bone health. **Hyperglycemia**. Thiazide diuretics cause hypokalemia; at the level of the pancreatic B cells, this hypokalemia causes hyperpolarization of the B cell and decreases insulin secretion. Decreased K in the interstitium keeps the K channels open for an extended time, which causes the hyperpolarization of the cell. This hyperpolarization does not allow the voltage-gated calcium channels to open. When intracellular calcium does not increase through calcium influx via the voltage-gated calcium channels, exocytosis of insulin granules does not occur in the pancreatic B cells. Hyperuricemia: increases risk of **gout**

Answer 9

Inserted into the **subclavian** or **jugular vein with** a tip in the **superior vena cava or right atrium.** It has **two** **lumens**, one for blood exiting the body (usually red) and one for blood entering the body (usually blue). They can **stay long-term and be used for regular haemodialysis.**

Answer 10

Skin integrity Aneurysms Palpable thrill (a fine vibration felt over the anastomosis) A “machinery murmur” on auscultation over the fistula

Answer 11

Blood flowing quickly from the arterial to the venous system through an A-V fistula. There is a **rapid return of blood to the heart:** i**ncreasing the pre-load** (how full the heart is before it pumps). This leads to **hypertrophy** of the heart muscle and heart failure. }}

Answer 12

**A – Acidosis** (severe and not responding to treatment) **E – Electrolyte** abnormalities (particularly treatment-resistant hyperkalaemia) **I – Intoxication** (overdose of certain medications) **O – Oedema** (severe and unresponsive pulmonary oedema) **U – Uraemia** symptoms such as seizures or reduced consciousness

Answer 13

**Tunnelled cuffed catheter:** * catheter that sits in a central vessels tunnelled under the skin and is usually present on the chest wall Tunneled Central Line for Childhood Cancer Patients - Together by St. Jude™ **Arteriovenous fistula**: * the most common and optimum. Surgical procedure takes place between an artery and a vein. The common sites are radio-cephalic, brachio-cephalic or brachio-basilic. Haemodialysis access with an arteriovenous fistula **AV graft:** * PTFE graft placed between artery and vein which can be used for dialysis

Answer 14

An **AV fistula is an artificial connection between an artery and a vein**. It bypasses the capillary system and allows blood to flow under high pressure from the artery directly into the vein. **This provides a permanent, large, easy-access blood vessel with high-pressure arterial blood flow**. Creating an A-V fistula requires a surgical operation and a maturation period of 4-16 weeks before it can be used.

Answer 15

**Radiocephalic** fistula at the wrist (radial artery to cephalic vein) **Brachiocephalic** fistula at the antecubital fossa (brachial artery to cephalic vein) **Brachiobasilic** fistula at the upper arm (less common and a more complex operation)

Answer 16

**Inadequate blood** flow to the limb distal to the fistula. The AV fistula “steals” blood from the rest of the limb. Blood is diverted away from the part of the limb it was supposed to supply, leading to **ischaemia**. Instead, it flows through the fistula and into the venous system.

Answer 17

**Thrombosis** of any 3 types · **Infection** (common in tunnelled dialysis) · **Failure of access** due to stenosis of central vessels or thrombosis, or no option for AV · **Fistula** can become aneurysmal · If there is high flow from a distal you can get distal ischemia known as **steal** **syndrome**

Answer 18

· Hypotension during dialysis · Reactions such as cramps and headaches · Inadequate dialysis dose · **Staphylococcus epidermis infection**

Answer 19

Peritoneal dialysis uses the **peritoneal membrane** to filter the blood. A special **dialysis** solution containing **dextrose** is added to the **peritoneal** **cavity**. Ultrafiltration occurs from the blood, **across the peritoneal membrane, into the dialysis solution**. The dialysis solution is replaced, taking away the waste products that have filtered out of the blood.

Answer 20

**Tenckhoff catheter** This plastic tube is inserted into the peritoneal cavity, with one end on the outside, allowing access to the peritoneal cavity to insert and remove the dialysis solution.

Answer 21

**Continuous ambulatory peritoneal dialysis:** - dialysis solution is always in the peritoneal cavity - The peritoneal cavity that is drained through a closed system via gravity **Automated peritoneal dialysis:** - Machine continously replaces the dialysis fluid every 8-10hrs

Answer 22

**Bacterial peritonitis**(infections in the high-sugar environment are common and serious) **Peritoneal sclerosis** (thickening and scarring of the peritoneal membrane; life threatening) **Ultrafiltration failure** (the dextrose is absorbed, reducing the filtration gradient, making ultrafiltration less effective) **Weight gain** (due to absorption of the dextrose) **Psychosocial implications**

Answer 23

**Coagulase-negative Staphylococcus** is the most common cause of peritonitis secondary to peritoneal dialysis. e.g. **Staphylococcus epidermidis**