Small Group 8 End-stage Renal Disease

Question 1

1. Recognize uremic symptoms and signs and laboratory abnormalities attributable to end-stage renal disease (ESRD).

Answer 1

symptoms: fatigue, anorexia, nausea and vomiting, decreased urination, pleuritic chest pain, decreased frequency and volume of urination
signs: HTN, weakness, waxy skin pallor, pale conjunctivae, pericardial rub
labs: severe anemia, hyperkalemia, AGMA, hyperphosphatemia, hypocalcemia, increased BUN and creatinine

Question 2

2. List reasons for starting chronic dialysis and know which are emergent.

Answer 2

emergent: severe volume overload (CHF, hypoxia) that is unresponsive to diuretics, lifer threatening hyperkalemia (>6.5), acidosis unresponsive to bicarbonate

signs include asterixis, if patient is not producing urine

Question 3

3. Understand the differences between the dietary prescription for a patient on dialysis versus a patient with CKD not on dialysis.

Answer 3

restriction of Na, P, K for both

with dialysis you have to add additional protein

Question 4

4. Know the three most common causes of ESRD.

Answer 4

DM
HTN
Glomerular disease

Question 5

5. List and briefly describe the common causes of renal allograft dysfunction.

Answer 5

rejection
toxicity of immunosuppressive drugs
infections
renal artery or ureteral obstruction
AKI: ATN**, AIN

Question 6

6. Recognize histologic and immunohistochemical features of renal allograft rejection.

Answer 6

acute cellular rejection: dense inflammatory infiltrate to the interstitial and renal tubules (tubilitis) with intimal arteritis; interstitial shows edema and focal microhemorrhage

Question 7

7. Describe the pathology , immune mechanism and clinical presentation of different types of transplant rejection: Immediate (hyperacute) rejection (antibody mediated)

Answer 7

preformed IgG against class HLA donor tissue (min-hrs)

is an antibody mediated cy
totoxic response to vascular endothelium, followed by thrombosis in the microvasculature and graft necrosis

endarteritis: characterized by endothelial swelling and undermining of the endothelium by lymphocytes

acute antibody mediated rejection of renal allograft shows diffuse C4d deposition in peritubular cpaillaries

Question 8

8. Describe the pathogenesis of hypertension in acute transplant recipients.

Answer 8

transplant renal after stenosis is a subacute complication that is usually associated with severe hypertension

Question 9

9. Describe the four causes of AKI in patients with a new kidney transplant, and list three appropriate tests to differentiate these causes.

Answer 9

vascular obstruction- ATN
urinary obstruction
drug toxicity- AIN
reperfusion injury

Question 10

10. Identify the primary kidney diseases that may recur in the transplanted kidney.

Answer 10

HUS
FSGS
Immunoglobulin A nephrophathy
Membranoproliferative glomerulonephritis
ANCA vasculitis
diabetic nephropathy
membranous nephropathy

Question 11

7. Describe the pathology , immune mechanism and clinical presentation of different types of transplant rejection: Delayed (accelerated acute) rejection (antibody mediated)

Answer 11

(days to months) manifested in renal tubular injury and neutrophil marination in peritubular interstitial capillaries

C4d serves as a durable marker of antibody mediated rejection

Question 12

7. Describe the pathology , immune mechanism and clinical presentation of different types of transplant rejection: Acute cellular (T-cell mediated) rejection

Answer 12

most common form of rejection (usually within first 6mo)

mediated by T cell infiltrate of allograft, undergo clonal expansion and cause tissue destruction (glomeruli, tubules, interstitial and blood vessels) commonly tubule-interstital

reaction to HLA class I and II antigens:
direct- receptors on host T cells recognize antigen on donor tissue
indirect- antigen presenting cells presents to helper T cells
production of cytosine, IL-2 which provides signals to helper cytotoxic T cells and promotes expansion of the T cell

Question 13

7. Describe the pathology , immune mechanism and clinical presentation of different types of transplant rejection: Chronic rejection

Answer 13

intimal hyperplasia and fibrosis of arteries
interstitial fibrosis
tubular atrophy
glomerulosclerosis of the graft

due to mixed humoral and cellular rejection, several types of chronic rejection include:

Chronic transplant glomerulopathy: GBM thickening with double contours and peripheral mesengial interposition

Chronic allograft nephropathy: ill-defined spectrum of changes of interstitial fibrosis and tubular atrophy with glomerulosclorsis often present