Renal LC

Question 1

Hb and iron studies

Answer 1

Hb 100-110

Aim ferritin >200 and Tsat >20%

Question 2

Renal complications

Answer 2

Blood:

anemia

Bones:

CKD-MBD

Electrolytes:

HyperK, metabolic acidosis (aim HCO2 <23), hyperphosphatemia

Neurology:

Peripheral neuropathy, sleep apnea, restless legs syndrome, fatigue/depression

Cardiac:

IHD, HTN

GI:

Anorexia, LOW

+ Volume overload

Question 3

KDIGO CKD stages by egfr

Answer 3

1 - egr >90
2 - 60-89
3A - 40-59
3B - 30-44

DIALYSIS TERRITORY (refer)
4 - 15-29
5 - <15

*make sure to include micro/macroalbuminuria!

Question 4

Indications for dialysis in CKD

Answer 4

Urgent - uremic encephalopathy/pericarditis/pleuritis

Non-urgent - declining nutritional status, refractory volume overload, worsening fatigue, MCI, refractory electrolyte disturbances (acidosis, hyperkalemia, hyperphosphatemia)

Question 5

Factors contributing to secondary hyperparathyroidism in CKD

Answer 5

Phosphate retention
Decreased free ionized calcium
Decreased activated vitamin D
Increased FGF23

Question 6

Lipid profile in CKD

Answer 6

Increased LDL, TG, VLDL

Decreased HDL

Question 7

When should statins be prescribed in CKD?

Answer 7

Age >50

Age <50 + + one or more of:

• CAD
• stroke
• diabetes
• estimated 10 year incidence of MACE >10%

Question 8

What foods are high in potassium?

Answer 8

Fruit - bananas, dried apricots, avocados, citrus
Veg - green leafy, potatos
Other - chocolate, milk, yoghurt

Question 9

Indicators of adequacy of dialysis

Answer 9

Symptoms (poor corelation) - fluid balance, uremia

UEs - normalization of K, urea reducation ratio >70% in HDx; weekly normalized urea clearance >2.0, Kt/V (target ~1.7)

Question 10

Absolute contraindications to renal transplant

Answer 10

Life expectancy problems

• Malignancy in the last 5 years (except prostate)
• Untreatable focus of infection
• Severe external disease

Surgical problems:

• Severe peripheral arterial/cerebrovascular disease
• Uncorrectable coagulopathy

Reversible problems:

• Reversible kidney failure
• BMI >35kg

Psychosocial problems:

• Documented ongoing treatment nonadherence (BUT EXPLORE THIS++++)
• Smoking/drug/alcohol dependence in last 6 months
• Significant untreatable psychosocial issues which would impair post-transplant care adherence

Question 11

Define CKD-MBD

Answer 11

One or more of

• Abnormalities of calcium, phosphate, parathyroid hormone (PTH), or vitamin D metabolism
• Abnormalities in bone turnover, mineralisation, volume, linear growth, or strength
• Vascular or other soft tissue calcification

Question 12

Findings in secondary hyperparathyroidism

Answer 12

Elevated serum phosphate
Low serum calcium
Low serum vitamin D
High serum PTH
ALP (bone origin) may also be elevated

Question 13

Findings in tertiary hyperparathyroidism

Answer 13

Elevated, normal or low serum phosphate
Elevated serum calcium
Very high serum PTH

Question 14

Forms of renal osteodystrophy

Answer 14

• adynamic bone disease
• osteomalacia
• osteitis fibrosa cystica
• mixed uremic osteodystrophy

Question 15

Management of CKD-MBD

Answer 15

Target PTH 2-9 ULN

Normalize calcium

Normalize phosphate - diet, phosphate binders (calcium carbonate, sevalelamer)

Activated vitamin D (calcitriol) once phosphate normalized

Cinacalcet in dialysis patients (increase sensitivity of calcium sensing receptor in PTH gland)

Parathyroidectomy

Question 16

Management of albuminuria in CKD

Answer 16

ACEi or ARB if no contraindications (monitor K)

Reduction in salt intake

Use of SGLT2i (T2DM)

Spironolactone if no contraindications (monitor K).

Question 17

High phosphate foods

Answer 17

Junk food - chocolate, cola
dairy products
seafood - oysters, sardines

Question 18

When should patients be referred for dialysis eduction/future planning?

Answer 18

Refer and educate for RRT at egfr <30ml/min

ALSO if developing significant complications