Renal Long Case

Question 1

CKD

Answer 1

1. Diagnosis
2. Risk factors/aetiology
   - family history
   - hypertension (RAS)
   - DM
   - PCKD
   - GN
   - nephrotoxins
   - progression - smoking, HTN, proteinuria, obesity, diabetes, AKI
3. Presentation
   - acute renal failure - uraemia, fluid overload, oliguria
   - urinary symptoms
   - urine output
   - symptoms of underlying dx
4. Investigations
   - determine renal function - UEC, urinalysis
   - renal tract imaging
   - Ix for causes - GN screen, kidney biopsy
   - Ix for complications - FBE, haematinics, CMP, PTH
5. Management
   - address underlying disease
   - renal replacement therapy (HDx, PD) + logistics
   - vascular access
6. Complications
   - fluid overload - FR, interdialytic weight gain
   - hypertension
   - renal anaemia - iron, EPO
   - CKD-MBD - diet, phosphate binders, PTH
   - uraemia
   - cardiovascular risk
   - sexual dysfunction
7. Outlook
   - impact on QOL/function/family
   - transplant?

Question 2

CKD (Examination)

Answer 2

1. Vital signs + BMI
2. Mental state
3. Fluid status
4. BP
5. anaemia + nutrition
6. access
7. abdomen
8. urinalysis
9. fundoscopy

Question 3

Transplant

Answer 3

1. Diagnosis, time on waitlist, graft number
2. Transplant history
   - live vs deceased
   - matching/ ABO/ HLA/DSA, sensitizing events/CMV
   - perioperative course (need for dialysis)
3. Monitoring
   - function
   - imaging
   - biopsies for rejection
4. Management
   - follow-up
   - immunosuppression, drug levels
   - infection prophylaxis
5. Complications
   - drug side effects
   - HTN, diabetes
   - infections/vaccinations
   - cancer screening
   - bone health
   - CVD risk management
6. Outlook
   - current graft function
   - impact
   - further dialysis?

Question 4

Transplant (Examination)

Answer 4

1. vital signs
2. BMI
3. blood pressure
4. Cushing’s
5. hirsutism/hair loss
6. access sites
7. graft site
8. features of infection

Question 5

What are the causes of deteriorating graft function in post-transplant patients?

Answer 5

1. conventional AKI
2. anatomical issues
   - vascular
   - ureter
3. medication related
4. recurrence of de-novo disease
5. transplant complications
   - chronic AMR
   - BK nephropathy
   - CNI toxicity

Question 6

What tests would you order for Babak’s deteriorating graft function?

Answer 6

1. Conventional AKI screen - UEC, urinalysis, medication review
2. Recurrence of de-novo disease
   - markers of activity - ESR, DsDNA, C3/C4 level
3. Anatomical
   - transplant Doppler US
   - MAG3 scan
4. Transplant complications
   - biopsy
   - BK virus level
   - CNI level

Question 7

How would you assess Babak’s risk of rejection?

Answer 7

1. Historical function
   - baseline graft function, trend
   - prior rejections
2. Historical rejection
   - previous biopsies?
   - previous grafts?
3. Antibody profile
   - HLA mismatch
   - donor specific antibodies
   - sensitising events
4. Patient profile
   - adherence problems
   - duration from transplant
   - level of immunosuppression

Question 8

What are Babak’s barriers to a repeat transplantation?

Answer 8

1. Patient factors
   - adherence
   - mental state
2. Disease factors
   - control of causative dx
   - comorbidities
   - weight
   - smoking
3. Immunological factors
   - availability of live donor
   - sensitising events
   - previous transplant complications/rejection