RRT

Question 1

When should dialysis be discussed?

Answer 1

less than 20ml/min

Question 2

When are patients referred to vascular surgeons for AVF?

Answer 2

15ml/min

Question 3

When can AVF and peritoneal catheter be used?

Answer 3

AVF: 6 weeks

Peritoneal catheter: 1-2 weeks

Question 4

When can patients be listed for transplant?

Answer 4

When within 6 months of dialysis

Question 5

Dialysis allows removal of what toxins that build up in CKD?

Answer 5

Urea
Potassium
Sodium

Question 6

Dialysis also allows infusion of what?

Answer 6

Bicarbonate (if acidotic)

Question 7

How does dialysis work?

Answer 7

Diffusion

Question 8

How does dialysis get rid of water?

Answer 8

Convection (water sucked out across membrane)

Filtration

Question 9

GFR in dialysis patients

Answer 9

10-12

Question 10

Too quick correction of metabolic issues =

Answer 10

Disequilibirum syndrome
Cerebral oedema
Seizures

Question 11

What restrictions does dialysis put on patient?

Answer 11

Fluid restriction 1L/day
Na restriction 3-4g/day
Glucose restriction
K restriction (low bananas/chocolate/potatoes)
Phosphate restriction (phosphate binders with meals)

Question 12

Pros of fistula

Answer 12

Good blood flow

Unlikely to cause infection

Question 13

Cons of fistula

Answer 13

Surgery
6 weeks to mature
Poor circulation in hand
Can block/thrombose

Question 14

Tunneled venous catheter

Answer 14

Catheter into large vein (jugular/subclavian/femoral/hepatic)

Question 15

Pros of TVC

Answer 15

Easy to insert

Can be used immediately

Question 16

Cons of TVC

Answer 16

High risk of infection
Damage to veins
Block

Question 17

Treatment of TVC infection

Answer 17

Vancomycin

Question 18

What can go wrong with HD?

Answer 18

Fluid overload
Blood leaks
Loss of vascular access
Hypokalaemia (cardiac arrest)
Intradialytic hypotension (removing large volumes)

Question 19

Peritoneal dialysis

Answer 19

Solute removal by diffusion across peritoneal membrane

Water removal by osmosis driven by high glucose concentration in dialysate fluid

Question 20

CAPD

Answer 20

Continual peritoneal dialysis

4 bag changes per day, 1/2 hour per exchange

Question 21

APD

Answer 21

Automated peritoenal dialysis
1 bag stays in all day
Overnight machine drains for 9-10 hours
Can take on holiday

Question 22

What can go wrong with PD?

Answer 22

Infection
Membrane failure = switch to HD
Hernia

Question 23

Treatment for PD infection

Answer 23

Vancomycin and Gentamicin

Question 24

Metabolic complications in ESKD

Answer 24

Bone metabolism (phosphate retention, low Vit D, hypocalcaemia because no Ca reabs, secondary hyperparathyroid = rickets)
Anaemia (epo/iron deificency)
Na and water retention
Accelerated CVD

Question 25

When to start dialysis based on bloods

Answer 25

Resistant hyperkalaemia GFR less than 5 Urea over 45 Unresponsive acidosis

Question 26

When to start dialysis based on symptoms

Answer 26

``` Fatigue Itch N+V Oedema unresponsive Loss of appetite Malnourished ```

Question 27

Cell surface receptors expressed on cells

Answer 27

HLA/MHC

Question 28

3 HLA types important in transplant

Answer 28

``` HLA-A (class I) HLA-B (class I) HLA-DR (class II) ```

Question 29

How can someone form HLA Abs?

Answer 29

Previous exposure to HLA Ag, e.g. blood transfusion, pregnancy, previous transplant

Question 30

Abnormal infections in transplant patients

Answer 30

``` CMV BK virus (viral changes in kidney) Recurrent UTI Pneumocystis jirovecii = co-trimoxazole NMSC Post-transplant lymphoma (EBV) ```

Question 31

How is rejection diagnosed?

Answer 31

Raised CK | Biopsy

Question 32

Hyperacute rejection

Answer 32

Minutes Due to preformed Abs (previous transfusion/transplant) Vascular thrombosis Unsalvageable = remove kidney

Question 33

Acute rejection

Answer 33

Early T or B cells Stop taking pills = acute rejection Increase immunosuppression

Question 34

Chronic rejection

Answer 34

Immunological and vascular deterioration of transplant

Question 35

Periods of immunosuppression

Answer 35

Induction Consolidation Maintenance

Question 36

How do calcineurin inhibitors work?

Answer 36

Inhibit activation of T helper cells = reduce NK activation and cytotoxic T cell activation Decrease cytokines = no B cells or Abs

Question 37

Example of calcineurin inhibitor

Answer 37

Cyclosporin | Tacrolimus

Question 38

Side effects of calcineurin inhibitor

Answer 38

``` Renal dysfunction HT Diabetes Tremor Drug interactions (cytochrom p450) ```

Question 39

How do aza and mycophenolate work?

Answer 39

Block purine synthesis = suppresses lymphocytes and B cells

Question 40

Side effects of aza and mycophenolate?

Answer 40

Leukopenia (low WCC), anaemia, GI side effects, careful in sun

Question 41

How do steroids work?

Answer 41

Non-selectively to suppress T cells and B cells

Question 42

Types of donor kidney

Answer 42

DBD DCD Live donor Kidney/Pancreas dual transplant

Question 43

DBD

Answer 43

Deceased brain dead - kidneys removed at same time as other organs, removed and put on ice

Question 44

DCD

Answer 44

Deceased cardiac death Only kidney and liver used Used by local centre

Question 45

Live donor

Answer 45

Usually family | Planned, well matched

Question 46

Dual transplant

Answer 46

Islet cells and kidney for T1DM

Question 47

Assessing patients for transplant

Answer 47

``` CV risk (ECG, echo, ETT, cholesterol) Virology (HBV, HCV, HIV, CMV, EBV) CXR (tumours) Bladder assessment Comorbidity ```

Question 48

Absolute contraindications for transplant

Answer 48

``` Malignancy (last 2 years, 5 if breast/colorectal) Untreated TB/latent TB Severe IHD Severe airways disease Severe PVD Active vasculitis ```

Question 49

How long is hospital stay for transplant?

Answer 49

7 days