Renal long case Flashcards
Differentials for CKD
T2DM
HTN
Reflux nephropathy
SLE/SScl
Polycystic kidneys
Glomerulonephritis
Severe AKI
Interstitial/analgesic nephropathy
Risk factors for CKD
- NSAIDs, radiocontrast, infection, ACEI/ARB, dehydration, anaemia
- Family history, vesicouroteric reflux/congenital urogenital abnormalities,
T2DM
HTN
vasculitis
renal calculi
gout
polycystic kidneys
History for CKD
nocturia, lethargy, loss of appetite, pruritis
limb swelling, oedema; haematuria, rashes, haemoptysis, joint issues
nephrotic syndrome, nephritic syndrome
Investigation for CKD
- 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
Management CKD - overall
Fluid overload/dialysis Dialysis planning/Transplant work up Anaemia Potassium/acidosis Metabolic bone disease Ureamic bleeding Restless legs Sexual dysfunction Cardiovascular risk factor control
Management CKD - dialysis planning
- Contraindications to Continuous Ambulatory PD or Automated PD – abdominal surgery, poor dexterity, poor social support, previous peritonitis, cognitive impairment)
- AV fistula creation
- Tencholff catheter creation
Management CKD - metabolic bone disease
- 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
Management CKD - fluid overload
- 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
A/CKD complication - differential
HTN, UTI, urinary obstruction, dehydration, cardiac failure; drugs
– contrast, NSAIDS, hypothyroidism, hypoadrenalism
Haemofiltration criteria
fluid overload, potassium, acidosis, toxins, pericarditis
Treatment for graft rejection
IV methylprednisolone, IV biologics (monoclonal Abs), plasma exchange Biopsy
Differentials – CMV, BK, systemic infection
Complications
Drug related
Opportunistic
infections
Neoplasm
Recurrence of glomerulonephritis
Cyclosporin complications
tremor
gout
hirsuitism
deranged LFTs
HTN
hyperkalaemia
low magnesium
gingival hypertrophy
renal impairment
Tacrolimus complications
tremor
T2DM
HTN
dyslipidaemia
squamous cell carcinomas
Prednisolone complications
- 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
Common opportunistic infections
BK
Cytomegalovirus
Pneumocystic jiroveci
Toxoplasma
Nocardia
Aspergillus
Management/control in CKD
- Surveillance of renal function, anaemia, phosphate, calcium urea
- Surveillance of DEXA/osteoporosis, weight bearing exercises, blood pressure, dyslipidaemia, LFTs and FBE
- Access to dialysis nurses, specialists, follow up with appointments
- Daily weights, fluid restriction, use of PD equipment, low salt, phosphate potassium diets
- Dietician input Avoidance of high risk activities predispose to infection, PJP and viral prophylaxis
- Avoidance of smoking and alcohol
- Up to date with childhood vaccinations, influenza and pneumococcus
History for chronic kidney disease
Cause of CKD
Uraemic symptoms - fatigue, anorexia, polyuria, nocturia, sleep disturbance, decreased appetite, nausea, vomiting, itch
Uraemic neuro complications - peripheral neuropathy, restless legs, pain asterixis, seizures, bone pain
Prior cardiac rhythm disturbances APO
Dialysis - commenced on dialysis, prior modalities, complications - peritonitis, dysequilibrium syndrome; fistula formation and complications
Producing urine
IHD risk factors and prior MI
Low potassium and phosphate diet
Fluid intake
Sexual dysfunction, menstrual disturbance
Management of CKD
Diet - reduce protein intake 1g/kg, sodium to 2g/day, potassium to 2g/day
Control BP - target 120/75, ACE/ARB
Fluid restriction and diuretics in dialysis patients
Anaemia of chronic disease - EPO when haematocrit falls below 30%; requires iron replacement at 3x normal Fe levels; Fe, B12 and folate levels regularly, may contribute to HTN
Renal osteodystrophy -Low phosphate diet and phosphate binders, 1,25OH Vit D supplementation, parathyroid removal surgery
Acidosis - oral bicarbonate therapy
Cardiovascular status - Cholesterol level, BSL, HbA1c, TTE, stress tests etc.
Spectrum of renal osteodystrophy
Hyperparathyroid disease - bone resorption and cyst disease, pepperpot skull
Osteoporosis
Osteomalacia
Osteosclerosis (secondary to hyperparathyroidism)
Adynamic bone disease - bone formation and resorption is impaired
Complications of chronic renal failure
Platelet dysfunction
Pruritis, pigmentation, calciphylaxis
Gastrointestinal complications - Diarrhoea, PUD, pancreatitis, constipation
Endocrinological - amenorrhoea, erectile dysfunction, infertility
Neurological complications - peripheral neuropathy, carpal tunnel syndrome, confusion, coma, seizures
Cardiovascular disorders - pericarditis, hypertension, peripheral vascular disease, CCF, myocardial fibrosis
Gout
T2DM
Pancreatitis
Renal osteodystrophy
Diagnostic criteria for Rheumatoid arthritis
Inflammatory arthritis involving three or more joints
Positive rheumatoid factor and/or ACPA
Duration greater than 6 weeks
Raised CRP and ESR
Exclusion of SLE, polyarticular gout, viral polyarthritis, seronegative arthritis
