Renal long case

Question 1

Differentials for CKD

Answer 1

T2DM
HTN
Reflux nephropathy
SLE/SScl
Polycystic kidneys
Glomerulonephritis
Severe AKI
Interstitial/analgesic nephropathy

Question 2

Risk factors for CKD

Answer 2

• NSAIDs, radiocontrast, infection, ACEI/ARB, dehydration, anaemia
• Family history, vesicouroteric reflux/congenital urogenital abnormalities, T2DM, HTN, vasculitis, renal calculi, gout, polycystic kidneys

Question 3

History for CKD

Answer 3

nocturia, lethargy, loss of appetite, pruritis; limb swelling, oedema; haematuria, rashes, haemoptysis, joint issues; nephrotic syndrome, nephritic syndrome

Question 4

Investigation for CKD

Answer 4

• For diagnosis – MSU, RT USS, CT-IVP; renal biopsy
• ANA complement,cryoglobulins, immunoelectrophoresis ANCA, Hep B/C, HIV,
• Ultrasound kidneys for size and post renal obstruction
• blood tests – eGFR, creatinine, urea; calcium/phosphate/magnesium; anaemia
• HTN management

Question 5

Management CKD - overall

Answer 5

Fluid overload/dialysis
Dialysis planning/Transplant work up
Anaemia
Potassium/acidosis
Metabolic bone disease
Ureamic bleeding
Restless legs
Sexual dysfunction
Cardiovascular risk factor control

Question 6

Management CKD - dialysis planning

Answer 6

• Contraindications to CAPD – abdominal surgery, poor dexterity, poor social support, previous peritonitis, cognitive impairment)
• AV fistula creation
• Tencholff catheter creation

Question 7

Management CKD - metabolic bone disease

Answer 7

• Calcium levels, phosphate levels, PTH level
• Phosphate binders with meals, low phosphate diet
• Tertiary hyperparathyroidism – parathroidectomy +/- autologous parathyroid transplant
• Vitamin D levels and calcitriol supplementation
• Osteoporosis, previous fractures, DEXA scan, bisphosphonate therapy

Question 8

Management CKD - fluid overload

Answer 8

• Making urine, dry weight, fluid restriction, diuretic therapy, salt restriction, dialysis days, access via car/taxi, travel; daily weights
• PD – bag changes, sterile technique, assistance from carer, daily weights, weight gain ‘action plan’, home dialysis nursing service
• Continuous ambulatory/ambulatory

Question 9

A/CKD complication - differential

Answer 9

HTN, UTI, urinary obstruction, dehydration, cardiac failure; drugs – contrast, NSAIDS, hypothyroidism, hypoadrenalism

Question 10

Haemofiltration criteria

Answer 10

fluid overload, potassium, acidosis, toxins, pericarditis

Question 11

Treatment for graft rejection

Answer 11

IV methylprednisolone, IV biologics (monoclonal Abs), plasma exchange
Biopsy
Differentials – CMV, BK, systemic infection

Question 12

Complications

Answer 12

Drug related
Opportunistic infections
Neoplasm
Recurrence of glomerulonephritis

Question 13

Cyclosporin complications

Answer 13

tremor
gout
hirsuitism
deranged LFTs
HTN
hyperkalaemia
low magnesium
gingival hypertrophy
renal impairment

Question 14

Tacrolimus complications

Answer 14

tremor
T2DM
HTN
dyslipidaemia
squamous cell carcinomas

Question 15

Prednisolone complications

Answer 15

• Osteoporosis, avascular necrosis of hip
• T2DM, HTN, dyslipidaemia
• Dysmorphic cushingoid features
• High doses - Electrolytes – potassium, proximal myopathy, mania, PJP/opportunistic infections
• Post op – reduced wound healing
• Cataracts
• Addisonism

Question 16

Common opportunistic infections

Answer 16

BK
Cytomegalovirus
Pneumocystic jiroveci
Toxoplasma
Nocardia
Aspergillus

Question 17

Surveillence/control in CKD

Answer 17

1. Surveillance of renal function, anaemia, phosphate, calcium urea
2. Surveillance of DEXA/osteoporosis, weight bearing exercises, blood pressure, dyslipidaemia, LFTs and FBE
3. Access to dialysis nurses, specialists, follow up with appointments
4. Daily weights, fluid restriction, use of PD equipment, low salt, phosphate potassium diets
5. Dietician input
   Avoidance of high risk activities predispose to infection, PJP and viral prophylaxis
6. Avoidance of smoking and alcohol
7. Up to date with childhood vaccinations, influenza and pneumococcus