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4th yr- CMS- Medicine > Renal impairment > Flashcards

Renal impairment Flashcards

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Introductory Sommelier Exam (CMS) flashcards
1
Q

What is included in renal replacement therapy

A

Renal dialysis and renal transplant

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2
Q

What is end stage renal failure

A

A situation where renal function has diminished to such an extend that renal replacement therapy is required to sustain life

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3
Q

What is end stage renal failure also referred as

A

Renal failure

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4
Q

What is renal impairment

A

A situation where renal function is sub optimal but renal failure hasn’t been breached

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5
Q

What is compromised renal function

A

An all encompassing term covering renal impairment and renal failure

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6
Q

Patients with which medical condition have some degree of renal impairment

A

Diabetes mellitus or hypertension

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7
Q

How many people in the UK require renal replacement therapy (RRT)

A

640 per million

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8
Q

What is the number of patients requiring renal replacement therapy influenced by?

A

Factors such as:

  1. More men than women receive Renal replacement therapy
  2. Asian or Afro-Caribbean and living in the U.K., then you are 3-5x more likely to have RRT
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9
Q

How much of the nHS budget is taken up by renal replacement therapy

A

2% (but expected to rise to 3%)

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10
Q

How much cardiac output do the kidneys receive

A

Around 20%

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11
Q

Where is blood is filtered through the kidney and what does it form?

A

blood is filtered through around 2 million glomeruli to form the glomerular filtrate (~180 litres/day or 2ml/second)
Extensivley modified as it passes through the renal tubes to form ruin

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12
Q

What is the daily urine output for a healthy adult

A

Varies by typically between 750-2000ml

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13
Q

What are the kidneys responsible for

A
  1. Maintenance of water and electrolyte balance
  2. Excretion of water products
  3. Acid base balance and pH
  4. Endocrine functions
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14
Q

Do the homeostatic mechanisms of the kidney ever stop?

A

nope due to the dietary intake of food maintenance of the correct electrolyte and fluid balance always needed

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15
Q

What is the glomerular filtrate made up of

A

Water and electrolytes that need to be reclaimed for further use

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16
Q

What is the recovery of ion in the kidney essential fro

A

Recovery of water which follows ions as a consequence of osmotic gradients

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17
Q

What is water reabsorption in the kidneys facilitated by

A

Ions recovery

Increased secretion of the hormone vasopressin from the pituitary gland

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18
Q

Which ions are excreted into the nephron

A

H+ and K, are excreted into the nephron after the primary glomerular filtrate has formed

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19
Q

Kidneys are essential for the secretion of what waste products from the blood

A
  1. Urea

2. Creatinine

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20
Q

What is Urea

A

The main nitrogenous waste product formed during the normal turnover and metabolism of protein

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21
Q

What is Creatinine

A

It formed reatine as a by-product of normal muscle metabolism:

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22
Q

How much muscle mass is turned over by the average adult

A

1.0-1.5kg of muscle mass every day

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23
Q

What can happen to the secretion of waste in diminished renal function

A

The levels of plasma level urea and creatinine rise as the number of glomeruli effetely working reduces

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24
Q

What are biological processes critically dependent on

A

pH

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25
Q

What can slight changes in pH do to proteins

A

Can affect protein folding an function

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26
Q

How are hydrogen ions generated in the body

A

Primarily by the metabolism of sulphur containing amino acids

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27
Q

How do the kidneys maintain the correct acid base balance

A

Via the secretion of H+ and bicarbonate reabsorption

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28
Q

What is endocrine function

A

Gland that secrete hormones

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29
Q

What hormones do the kidneys produce

A
  1. erythropoietin

2. Renin

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30
Q

What is the role of erythropoietin

A

Up regulates the production of erythrocytes

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31
Q

What are erythrocytes

A

Red blood cells

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32
Q

What does renin act within

A

the renin-angiotensin-aldosterone pathway

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33
Q

What does renin stimulate

A

Release of angiotensin I which is converted to angiotensin II:

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34
Q

What is the significance of Angiotensin Converting Enzyme (ACE)-inhibitors

A

They reduce the conversion of angiotensin I to angiotensin II

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35
Q

What are Angiotensin Converting Enzyme (ACE)-inhibitors used in

A

The are a major class of drugs used in the management of hypertension, diabetic nephropathy, heart failure and following myocardial infarction;

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36
Q

What can be used in place of Angiotensin Converting Enzyme (ACE)-inhibitors

A

Angiotensin II receptor antagonists

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37
Q

What does Angiotensin do

A

Stimulates the release of aldosterone from the adrenal Cortex

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38
Q

What does aldosterone do

A

Promotes renal reabsorption of Na+ and consequently water to help raise blood pressure by increasing the circulating volume.

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39
Q

Which vitamin is the kidney responsible fro metabolising

A

Vitamin D

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40
Q

Why is vitamin D important

A

For normal bone turnover

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41
Q

How is vitamin D metabolised

A

Vitamin D undergoes 1-hydroxylation in the kidney to form 1,25- dihydroxycholecalciferol, which promotes Ca2+ absorption from the intestine;

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42
Q

What happens as Ca2+ levels fall

A

Phosphate levels rise

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43
Q

What happens fi vitamin D levels are reduces

A

Ca2+ levels fall
Phosphate levels rise
Increased release of Parathyroid Hormone

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44
Q

Where is the Parathyroid Hormone released from

A

The anterior pituitary gland

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45
Q

why is the Parathyroid Hormone released in response to falling vitamin D levels

A

in an attempt to correct blood Ca2+ concentrations.

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46
Q

What can happen is there’s chronic disruption of Ca2+ metabolism

A

Can result in renal bone disease

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47
Q

What are most cases of renal impairment and failure due to

A
  1. Diabetes mellitus
  2. Hypertension
  3. Congenital causes
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48
Q

List some Congenital causes of renal impairment and failure

A
  1. Autosomal Dominant Polycystic Kidney Disease

2. Alport’s syndrome.

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49
Q

How common is Autosomal Dominant Polycystic Kidney Disease

A

1 in 1000

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50
Q

What causes Autosomal Dominant Polycystic Kidney Disease

A

Dysfunction of the PKD1 and PKD2 genes results in formation of multiple renal cysts

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51
Q

How many patients with Autosomal Dominant Polycystic Kidney Disease develop end stage renal failure

A

Around 50% by the age of 55%

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52
Q

How many patients on renal replacement therapy have Autosomal Dominant Polycystic Kidney Disease

A

10%

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53
Q

Give examples of acquired causes of renal impairment and failure

A
  1. Diabetic Nephropathy
  2. Hypertension Nephropathy
  3. Renovascular disease
  4. Connective tissues diseases
  5. Infections such as HIV.
  6. Cancers
  7. Iatrogenic such as drug use
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54
Q

Name the leading cause of renal failure

A

Diabetes mellitus

55
Q

How many patients on dialysis have Diabetes mellitus

A

20-50%

56
Q

Name the 2 types of Diabetes mellitus

A

Type 1 and 2

57
Q

When does Diabetic Nephropathy reach its peak in type one diabetics

A

15 years following diagnosis of type 1 diabetes

58
Q

Does everyone with type 2 diabetes develop Diabetic Nephropathy

A

No varies with race

59
Q

How many caucasians with type 2 diabetes go on to develop Diabetic Nephropathy

A

25%

60
Q

How many Asian Indians with type 2 diabetes go on to develop Diabetic Nephropathy

A

50%

61
Q

How many African-caribbeans with type 2 diabetes go on to develop Diabetic Nephropathy

A

50%

62
Q

How common is hypotension in diabetes

A

30-50% of those with type 1

20% of those in type 2

63
Q

What is Renovascular disease

A

Atherosclerosis of the renal arteries

64
Q

List connective tissue disease that can lead to renal impairment and failure

A

Systemic lupus erythematosis

65
Q

Which cancers can lead to renal impairment and failures

A

lymphomas, myeloma and carcinomas.

66
Q

List some clinical features of renal impairment and failure

A
  1. Acute renal failure
  2. Chronic renal failure
  3. renal Osteodystrophy
67
Q

What can renal impaireent and failure be assocated with

A
  1. Cardiovascular disease
  2. Anaemia
  3. Abnormalities of coagulation
  4. Renal bone disease
  5. Malnutrition
  6. Tissue oedema
  7. Impairment of the immune system
  8. Malignancy
  9. Sexual dysfunction and pregnancy
  10. Mental health problems
68
Q

What is acute renal failure

A

It is the abrupt loss of normal renal functions

69
Q

Give examples of some abnormal renal functions

A
  1. Oliguria
  2. Retention of nitrogenous waste (urea) and creatine
  3. Loss of normal electrolyte, water and pH homeostasis
70
Q

What is Oliguria characterised as

A

Urine volume of <400ml/day

71
Q

List the key features of acute renal failure

A
  1. Loss of normal electrolyte and fluid homeostasis

2. Metabolic acidosis

72
Q

What happens to the kidney is acute renal failure

A

They lose their ability to excrete or conserve electrolytes in an appropriate way with associated disruption of fluid balance

73
Q

What can happen as a result of the loss of normal electrolyte and fluid homeostasis

A

Hyperkalaemia (high levels of K+) can result in arrhythmias

74
Q

what causes metabolic acidosis

A

The kidneys losing their ability to maintain a normal acid base mechanism

75
Q

Is acidosis fatal

A

It is associate with a high morbidity and mortality

76
Q

is acute renal failure fatal

A

It has a high mortally rate 35-80%

77
Q

What is the relationship between cardiovascular disease and chronic renal failure

A

Cardiovascular disease is 3-5 times more common in those with chronic renal failure than without

78
Q

What does cardiovascular disease with renal failure include

A
  1. Coronary heart disease

2. Heart failure

79
Q

Why might the pathology of cardiovascular disease be different in a patient with renal failure

A

may relate to high urea levels:

  1. Uraemic vasculopathy
  2. Uraemic cardiomyopathy
80
Q

Why is anaemia clinically important in chronic renal failure

A
  1. Patients are tired, lethargic, breathless, limited exercise tolerance, muscle fatigue
  2. Reduced oxygen carriage in anaemia can contribute to symptomatic cardiovascular disease
  3. The oral manifestations of anaemia may be the first clinical signs of undiagnosed anaemia
81
Q

Talk through the origin of anaemia in chronic renal failure

A
  1. Diminished production and function of erythropoietin
  2. Anaemia of chronic disease
  3. Inappropriate haemolysis of erythrocytes;
  4. Blood loss via the gastrointestinal tract when there is prolonged bleeding
82
Q

What can chronic renal failure be associated with in terms of coagulation

A
  1. Prolonged bleeding

2. Prothrombotic states

83
Q

What does prolonged bleeding in chronic renal patients relate to

A

Abnormal platelet funciton

84
Q

Why is normal platelet function essential

A

For clot formation

85
Q

Why with Prothrombotic States be related to

A
  1. Altered endothelial cell function

2. Altered coagulation factor production and function

86
Q

What effect can chronic renal failure have on bone

A

Can impact bone metabolism resulting in bone that turns over too rapidly or too slowly

87
Q

Describe the bone in renal Osteodystrophy

A
  1. Poor quality
  2. Prone to fracture
  3. metastatic calcification in soft tissue
88
Q

What is metastatic calcification

A

inappropriate calcification; nothing to do with cancer

89
Q

Which hormone is affected in renal Osteodystrophy

A

Excess parathyroid hormone released leading to secondary hyperparathyroidism.

90
Q

What can Osteoporosis be marked by

A

1 .Long term use of systemic corticosteroids

2. Following renal transplant

91
Q

What is tissue oedema in chronic renal failure related to

A
  1. Reduces plasma protein concentration

2. An increase int eh total sodium ion content

92
Q

Describe urine in health

A

Very little protein present

93
Q

When urine testing talk through A significant findings

A

Detection of proteinuria (protein in the urine)

94
Q

What can proteinuria suggest

A

Damage to the glomeruli

95
Q

What can damage to the glomeruli result in

A
  1. High levels of protein in the urine
  2. Low levels of protein in the blood
  3. Dyslipidaemia
96
Q

What is the most common cause of proteinuria

A

Diabetic nephropathy

97
Q

What can chronic protein loss in urine lead to

A

Reduced osmotic pressure in the blood leading to excess fluid leaving the capillaries and being retained in the tissues
tissue oedema

98
Q

What can and excess total body Na+ result in

A
  1. Fluid retention
  2. tissue oedema
  3. Hypertension.
99
Q

What is renal dialysis associated with in terms of sexual health

A
  1. Reduced levels of testosterone and erectile dysfunction

2. Amenorrhoea

100
Q

What can childhood developed chronic liver failure present as

A

Impact on:

  1. Physical growth and development
  2. Education
  3. Development of social skills
101
Q

How can we diagnose and monitor renal impairment and failure

A
  1. Urea, creatine and electrolysis levels
  2. Urine volumes
  3. Urine microscopy
  4. Blood tests
  5. Imaging
  6. Renal biopsy
102
Q

Name the most widely used test for Renal function

A

urea, creatinine and electrolyte LEVELS

103
Q

Renal impairment can have a profound effect on drug what?

A
  1. Pharmacokinetics

2. Pharmacodynamics

104
Q

How can drug Pharmacokinetics be affected by Renal impairment

A
  1. Active drugs and/or their active metabolites will accumulate with potentially adverse effects,
  2. The activity of some drugs is influenced by their degree of protein binding, which can be changed in renal impairment.
105
Q

How can drug Pharmacodynamics be affected by Renal impairment

A

The sensitivity of the target tissues to specific drugs may be either increased or decreased with potentially adverse effects.

106
Q

Which drugs used in dentistry should we be cautious of prescribing to patients with renal failure

A
  1. Aspirin and NSAIDs;
  2. Opioid analgesic drugs including compound preparations
  3. Amoxicillin, ampicillin and related drugs;
  4. Cefalexin and related drugs;
  5. Flucloxacillin;
  6. Tetracyclines;
  7. Fluconazole and related drugs;
  8. Acyclovir.
107
Q

What are the symptoms of renal impairment

A

Initially asymptomatic

108
Q

What are the aims of management fro renal failure

A
  1. Limit an y further renal damage
  2. Improve renal function
  3. introduce renal replacement therapy
109
Q

How can we manage renal failure

A
  1. Low protein diet
  2. Management of hypertension
  3. Suppression of the immune system
  4. Management of Dyslipidaemia
110
Q

How can we manage hypertension in kidney failure

A

By using ACE inhibitors

111
Q

What does renal replacement therapy include

A
  1. Dialysis

2. Human kidney transplant

112
Q

Name the 2 types of dialysis

A
  1. Haemodialysi;

2. Peritoneal dialysis

113
Q

How many times do patients need to undergo Haemodialysi

A

3 times a week each sessionlastign several hours

114
Q

What does dialysis involve

A

Movement of solutes and water across a semi permeable membrane

115
Q

Talk through the diffusion that occurs when on dialysis

A

small molecules such as urea (60 Daltons) pass across the membrane (removed from the blood),
larger molecules such as albumin (60,000 Daltons) do not so are retained in the blood

116
Q

Which drug is used in conjunction with a dialysis machine

A

Heparin

117
Q

Why is heparin giving to patients on dialysis

A

To prevent blood clotting triggers by the dialysis machine

118
Q

Name some complications associated with renal replacement therapy

A
  1. accelerated atherosclerosis, hypertension and anaemia:

2. Increased risk of blood borne viruses

119
Q

Name an alternative to haemodialysis

A

Peritoneal Dialysis

120
Q

What is the advantage of peritoneal Dialysis

A

Can be done at home

121
Q

What happens in peritoneal Dialysis

A
  1. A catheter is inserted into the peritoneal cavity
  2. Dialysis fluid is introduced into the peritoneal cavity
  3. The peritoneum acts as the dialysis membrane;
122
Q

Talk through the typical regime of Peritoneal Dialysis

A

is to introduce and drain 2 litres of dialysis fluid on four occasions within a 24 hour period

123
Q

Name a common complication of peritoneal Dialysis

A

Peritoneal infection

124
Q

Which has a higher survival rate peritoneal Dialysis or haemodialysis

A

Both have a similar survival rate

125
Q

What is the preferred option for end stage renal failure

A

Renal tranplantation

126
Q

Where can donor kidneys come from for kidney transplantation

A
  1. Deceased donors

2. Living donors (more common in UK)

127
Q

How can we reduce the risks of complications for a kidney transplant

A

Matching of the donor ro the recipient

128
Q

List some complications and outcomes of kidney transplantation

A
  1. Graft loss
  2. Cardiovascular disease
  3. Hypertension
  4. Dyslipidaemia;
  5. Diabetes mellitus;
  6. Obesity;
  7. Metabolic bone disease;
  8. Anaemia, leucopenia or thrombocytopenia;
  9. Post-transplant cancers – related to immunosuppression:
129
Q

What is the percentage fo graft survival 1 year post op

A

90%

130
Q

What is the percentage fo graft survival 5 year post op

A

80%

131
Q

Name the 2 major cases of graft loss

A
  1. Chronic allograft nephropathy

2. Death, usually due to cardiovascular disease with a functioning transplanted kidney.

132
Q

What risk assessment do we carry our fro our patients who have renal disease

A
  1. Identify underlying cause
  2. Known or unknown blood Bourne virus infection risk
  3. Past, current or planned treatment
  4. Patient complaint
133
Q

How can dentists contribute to the diagnosis of renal impairment

A

1, Oral manifestations leading to new diagnosis of diabetes

  1. Oral manifestation of anaemia
  2. Increased propensity for infection such as oral candidiasis
  3. Uraemic stomatitis
134
Q

What is Uraemic stomatitis characterised by

A
  1. Unpleasant taste and breath that smells of ammonia;

2. A thick grey pseudomembrane overlying areas of oral mucosa that may be ulcerated.

4th yr- CMS- Medicine (14 decks)

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