Renal patient in abdomen station (incomplete) Flashcards
Framework of approach to renal patient in abdomen station
A. Identify current mode of RRT
B. Identify previous mode(s) of RRT
C. Adequacy of RRT (uraemia, volume status)
D. Complications of renal failure (anaemia)
E. Complications of immunosuppressants in renal transplant
F. Identifying etiology of renal disease (if possible)
G. Wishlist - BGM, urinalysis, pericardial rub
A. Identify current mode of RRT
- Tunneled catheter - usually left/right subclavicular area
1A. Check for exit site infection - Arteriovenous fistula (AVF) - usually over non-dominant UL, rarely over LL
2A. Maturity/stenosis/thrombosi - thrills, bruit - Peritoneal dialysis - Tenchkoff catheter over abdomen, with fluid in peritoneal cavity
3A. Check for exit site infection - Renal transplant - RIF fossa scar (Rutherford-Morrison scar) with smooth mass below +- bilateral IF fossa scar (double transplant)
- Margins (smooth), size (8x5cm usually), tenderness, consistency (firm), dull percussion, bruit (absent)
B. Previous modes of RRT
- Scars over subclavicular area
- Previous AVF - non-functioning/still functioning
- Abdominal wall scars - PD
- Laparotomy scars - peritonitis necessitating surgery
C. Adequacy of RRT
D. Complications of RRT
Fluid status
1. Lung crepitations
2. Elevated JVP
3. Pedal oedema, or worse anasarca
Uraemia
1. Altered mental status (relevant negative absent in PACES)
2. Asterixis (metabolic encephalopathy)
3. Excoriation marks (pruritus)
4. Tachypnoea (metabolic acidosis with respiratory compensation)
5. Pericardial rub (uraemic pericarditis)
Anaemia - important negative/positive
E. Complications of ISTs in renal transplant
Upon confirmation of renal transplant
1. Stigmata of infection
2. Skin lesions - both benign or malignant
3. Cyclosporin - gum hypertrophy, hirsutism, coarse tremor, hypertension, DM
4. Steroids - purpura, cushingoid, DM
5. Tacrolimus - DM
F. Identifying etiology of renal disease
G. Wishlist
Possible etiologies of renal disease
1. Diabetes - fingerpricks, lipodystrophy, DM retinopathy
2. Hypertension - check blood pressure
3. Vasculitis - skin lesions, rheumatological disease, SLE
4. ADPKD - palpable and ballotable native kidneys, previous nephrectomy scars
5. Alport’s syndrome - hearing aid
6. Tuberous sclerosis - subungal fibromas sebaceous aderomas
7. MPGN - face/upper trunk/arms lipodystrophy
Wishlist
1. Blood glucose monitoring
2. Urinalysis
3. Pericardial rub
What are the commonest cause of chronic kidney disease?
- Diabetes mellitus
- Glomerulonephritis
- Hypertension
- Miscellaneous - drug indiced, paraproteinaemia, obstructive uropathy
- Polycystic kidney disease
- Reflux nephropathy
- Analgesic nephropathy
- Uncertain
Principles of management of CKD
A. Treatment of reversible causes of renal dysfunction
1. Diagnosis of treatable glomerular disease - biopsy
2. Cessation of nephrotoxic drugs - diuretics, NSAIDs, antibiotics
3. Exclusion of obstructive uropathy and renovascular disease - US KUB
B. Slowing disease progression
1. Control hypertension
2. Control CVRF
C. Treatment of complications of CKD
1. Volume overload - diuretics
2. Hyperkalaemic - potassium restriction, diuretics, bicarbonate, K binding agents
3. Hyperphosphataemia - phosphate binders
4. Metabolic acidosis - sodium bicarbonate
5. Renal osteodystrophy - Vit D, control hyperphos, parathyroidectomy
6. Anaemia - iron replacement, erythropoietin analogue
What are indications of RRT?
Preparation when eGFR < 30
Indications:
1. Acidosis
2. Electrolyte abnormalities - hyperkalaemia
3. Intoxications - lithium, salicylate, etc
4. Overload status refractory to diuretics
5. Uraemia
- Pericarditis, pleuritis, encephalopathy
- Uraemic coagulopathy (platelet dysfunction)
What are the differential diagnoses of bone pain in renal patients?
- Osteitis fibrosa
- Osteomalacia
- Dialysis related amyloid
- Myeloma or skeletal metastasis
- Osteomyelitis - bacteraemia from vascular access
- Neuropathic pain from nerve compression of AVF
What are the manifestations of renal osteodystrophy?
- Osteitis fibrosa - increased bone turnover due to secondary hyperparathyroidism causing bone pain, tenderness, bone cysts
- Osteomalacia - decreased mineralisation of bone due to aluminum-containing phosphate binders
- Adynamic bone disease - reduced bone turnover
What are the problems associated with haemodialysis?
- Dialysis overfiltration/washout - rapid fluid and electrolyte removal - hypotension, fatigue, chest pain, leg cramps, nausea, headache
- Bacteraemia from catheter infection, commonly SA
- Bleeding - heparin use during HD
- Beta-2 microglobulin amyloidosis - CTS, scapulohumeral arthropathy, spondyloarthropathy, bone cysts, pathological fracture
What are the problems associated with peritoneal dialysis?
- Bacterial peritonitis
- Solute clearance or ultrafiltration failure
- Diabetes mellitus - absorption of glucose from dialysate
- Local complications - abdominal wall hernia, fluid leakage into soft tissue
