Urinary Session 11 Flashcards
1
Q
What happens to renal tissue in CKD?
A
Replaced by extracellular matrix and fibrosis in response to tissue damage
2
Q
What can be used in addition to eGFR to assess renal function?
A
Albumin-creatinine ratio
3
Q
What proportion of nephrons need to be working in a kidney in order for renal function to be sufficient?
A
2%
4
Q
What is the aetiology of CKD?
A
Immunologic - glomerulonephritis Infection - chronic pyelonephritis Genetic - polycystic kidney, Alport's Obstruction and reflex nephropathy Hypertension Vascular - vasculitis, arteriosclerosis, IHD Systemic disease - DM, myeloma Idiopathic
5
Q
What are the commonest causes of CKD?
A
Diabetes
Idiopathic
6
Q
Which cause of CKD gives rise to an exception to the common histological appearance of CKD?
A
Polycystic kidney
7
Q
What is the pathogenesis of CKD regardless of aetiology?
A
Loss of renal parenchyma and tubules with formation of scar tissue and infiltration by inflammatory cells
8
Q
How does the incidence of CKD change relative to staging?
A
Decreases as staging increases
9
Q
What is associated with CKD pts who inexorably worsen?
A
CVS morbidity and mortality, often before GFR decrease requires dialysis
10
Q
Does early recognition and intervention cure CKD?
A
No, delays rate of decline and delays need for dialysis but most pts decline anyway
11
Q
When does mortality start to increase in CKD?
A
Once eGFR has decreased by 25%
12
Q
What is chronic kidney disease?
A
Irreversible +/- progressive loss of renal function over a period of months to years
13
Q
What investigations are used in CKD to define the degree of impairment?
A
BP Urine dipstick Serum creatinine Inulin clearance Cr EDTA clearance Iohexol clearance Creatinine clearance eGFR
14
Q
What is proteinuria proportional to in CKD?
A
Development of end-stage renal disease therefore more protein –> steeper decline in eGFR
15
Q
Does a serum creatinine level within the normal range of 80-120 micromoles per litre always indicate normal renal function?
A
No, depends on renal function and muscle mass which is affected by age, sex and with city
16
Q
Why are inulin, Cr EDTa and iohexol clearance impractical measures of renal function in CKD?
A
Must be IV, need time in hospital and use of radiation is unpopular
17
Q
Why is creatinine clearance not a good assessment of renal function in CKD?
A
Impractical, inaccurate and time consuming (must be done over 24 hr period)
18
Q
Can eGFR be used to assess a child’s renal function?
A
No, adults only
19
Q
How can the cause of CKD be assessed?
A
Autoantibody screen for lupus/myeloma Complement, Ig, ANCA for vasculitis, CRP levels Serum/urine proprotein electrophoresis US for size and hydronephrosis CT, MRI Biopsy
20
Q
When is the kidney biopsied in CKD?
A
If kidneys are normal size and there is no obvious CKD cause
21
Q
What are the possible complications of CKD?
A
Metabolic acidosis
Normocytic and normochromic anaemia
Metabolic bone disease
22
Q
How does CKD lead to metabolic acidosis?
A
Diseased kidney cannot regain HCO3- –> loss of HCO3- —> decreased HCO3-/CO2 ratio –> decreased pH in blood
23
Q
What are the consequence of metabolic acidosis in CKD?
A
Muscle function impairment
Decreased bone mass
Worsened renal function decline
24
Q
What is the Tx for metabolic acidosis in CKD?
A
Oral NaHcO3- tablets
25
How does CKD cause anaemia?
Decreased EPO production and increased resistance --> decreased RBC survival --> blood loss
26
What is renal osteodystrophy?
Sclosis of vertebral end plates and erosion of terminal phalanges
27
How does CKD cause metabolic bone disease?
Decreased GFR --> increased phosphate retention
--> decreased calcium levels --> increased PTH --> osteitis fibrosa cystica
Decreased GFR --> decreased activation of vitamin D --> osteomalacia --> increased PTH and non-bone calcification
28
How is metabolic bone disease in CKD treated?
Supplements
29
What potentially modifiable risks can be targeted in management of CKD?
```
Smoking
Obesity
Lack of exercise
Tx DM and hypertension
In proteinuria use ACEI/ARBs and consider lipid lowering Tx
```
30
When is renal replacement therapy used to manage CKD?
Native renal function decreases and can no longer support health
31
What symptoms indicate renal replacement therapy with dialysis in CKD?
```
Uraemic symptoms
Acidosis
Pericarditis
Fluid overload
Hyperkalaemia
```
32
What is end-stage renal failure?
When death is likely without renal replacement therapy
33
What is the numerical definition of ESRF?
eGFR
34
What are the S/S of ESRD?
```
Tiredness
Difficulty sleeping
Difficulty concentrating
SoB and oedema due to volume overload
N+V/reduced appetite
Restless legs and debilitating cramps
Pruritis
Sexual dysfunction with decreased fertility
Increase in number of infections
```
35
What causes an increase in number of infections in ESRD?
Impaired cellular and humoral immunity
36
What is the effect of CKD in water/salt handling when GFR is small but the solute load is the same?
Osmotic diuresis due to impaired maximum concentrating ability and reduced response to ADH --> nocturia
37
What is the effect of CKD on renal water/salt handling when the volume of filtrate is reduced?
Impaire ability of kidney to excrete substances --> decrease in max urine volume
38
Why do 80-85% of CKD pts have altered water/salt handling?
They are hypertensive and are taking anti-hypertensives/diuretics/fluid restricted
39
Why might muscle or bone pains be felt in acid abase balance and electrolyte disturbances due to CKD?
Acidosis --> hyperphosphataemia and decreased 1-alpha-calcidiol --> bone breakdown
Acidosis --> muscle wasting
40
If there a definitive threshold in the accumulation of waste products and onset or uraemic symptoms?
No
41
Why do most drugs need dose altering in CKD/ESRD pts?
Decreased metabolism +/- elimination
| Increased sensitivity without impairment of elimination --> increased likelihood of S/E
42
What are the advantages of using haemodialysis for renal replacement therapy?
Less responsibility for Tx
| Days off between dialysis sessions so can forget illness
43
What are the disadvantages of haemodialysis Tx?
Travel and waiting time
Restriction of dialysis times
Big restriction of fluid and food intake
Unsightly fistulas which start at wrist so difficult to cover
44
Why is home/nocturnal haemodialysis considered better than in hospital?
Gives more dialysis hours --> better large molecule clearance --> pt fells better and needs less supportive Tx but requires second person to be present due to haemorrhage risk
45
Describe the process of haemodialysis.
Arterial access drains into machine, pressure is monitored throughout and blood pumped round. Anticoagulant is added, then blood flows in opposite direction to diasylate within the dialyzer to exchange solutes. Processed blood returned to venous system
46
How does the K+ concentration of diasylate fluid in haemodialysis compare to that of blood?
Lowe than you want in blood returning to body so it moves out in dialyzer
47
What are the contraindications for haemodialysis?
Failed vascular access
Heart failure due to machine decreasing preload
Coagulopathy
48
What complications arise as a result of haemodialysis?
Lines --> infection, thrombosis, venous stenosis
AVF --> thrombosis, bleeding, access failure, steal syndrome causing an ischaemic hand
CVS instability
Felling chronically unwell
Accumulation of co-morbidities
49
Does peritoneal dialysis require more or less supplementary Tx (additional tablets and injections) than haemodialysis?
Fewer
50
What are the advantages of permit penal dialysis?
Self-sufficient
Less fluid and food restrictions
Fairly easy to travel with
Renal function better preserved initially
51
What is in the diasylate fluid in peritoneal dialysis?
Sugar or polymer
52
What are the disadvantages of peritoneal dialysis?
Frequent daily exchanges or overnight
Responsibility
No days off from illness
53
What are the contraindications for peritoneal dialysis?
Failure of peritoneal membrane e.g. due to scar from surgery
Adhesions, hernia, stoma
Pt or carer cannot connect/disconnect
Obese or large muscle mass due to reduced SA/volume
54
What complications are associated with peritoneal dialysis?
```
Peritonitis (typically experienced once ever 20 months)
Site infections
Ultrafiltration failure
Leaks into scrotum or diaphragm
Development of hernia
```
55
What is the difference between continuous ambulatory peritoneal dialysis and ambulatory peritoneal dialysis?
Continuous = 4-5 bags per day whereas other is overnight
56
What are the three different methods of kidney transplant currently available?
Live donor
Deceased after brain death (DBD)
Deceased after circulatory death (DCD/non-heart beating)
57
What are the advantages of kidney transplant for renal replacement therapy?
Decreased mortality and morbidity in comparison to dialysis
| Better QoL
58
What are the disadvantages of kidney transplant as a renal replacement therapy?
Peri-operative risk (mortality highest for 3 months after)
Malignancy risk
Infection risk
Diabetes and hypertension risk from additional medication required
59
Describe the process of kidney transplant.
Pt on waiting list --> accrues points based on age and waiting time --> tissue match by blood group(ABO) and MHC class I(HLA)--> attach new kidney to iliac arteries
60
What morbidity does transplant medication cause due to its side effects?
```
Diabetes
Hypertension
GI ulceration
Decreased WCC and platelets
Steroid S/E
```
61
Which type of kidney transplant has the best average transplant life?
Live related donor
62
What is the numerical definition of kidney failure?
eGFR
63
How long does dialysis prolong life for in pts >70 y.o. with ESRD and significant CVD co-morbidities?
~2 years
64
Why do some pts >70 y.o. with ESRD and significant co-morbidities choose not to have dialysis?
Can survive a substantial length of time (although
65
Which co-morbidities confer a particularly poor outcome for elderly dialysis pts?
CVD
66
How does the mortality of ERSD pts compare to age matched pts without ERSD?
It is higher
67
When do pts die from ERSD?
If dialysis access is not possible otherwise CVD cause in dialysis or malignancy in transplant pts
68
What is the average life expectancy for a pt aged 25-29 with incident ERSD?
18 years from diagnosis
69
What is the average life expectancy for an incident ERSD pt aged 75 years?
3 years from diagnosis
70
Why might muscle or bone pains be felt in acid abase balance and electrolyte disturbances due to CKD?
Acidosis --> hyperphosphataemia and decreased 1-alpha-calcidiol --> bone breakdown
Acidosis --> muscle wasting
71
If there a definitive threshold in the accumulation of waste products and onset or uraemic symptoms?
No
72
Why do most drugs need dose altering in CKD/ESRD pts?
Decreased metabolism +/- elimination
| Increased sensitivity without impairment of elimination --> increased likelihood of S/E
73
What are the advantages of using haemodialysis for renal replacement therapy?
Less responsibility for Tx
| Days off between dialysis sessions so can forget illness
74
What are the disadvantages of haemodialysis Tx?
Travel and waiting time
Restriction of dialysis times
Big restriction of fluid and food intake
Unsightly fistulas which start at wrist so difficult to cover
75
Why is home/nocturnal haemodialysis considered better than in hospital?
Gives more dialysis hours --> better large molecule clearance --> pt fells better and needs less supportive Tx but requires second person to be present due to haemorrhage risk
76
Describe the process of haemodialysis.
Arterial access drains into machine, pressure is monitored throughout and blood pumped round. Anticoagulant is added, then blood flows in opposite direction to diasylate within the dialyzer to exchange solutes. Processed blood returned to venous system
77
How does the K+ concentration of diasylate fluid in haemodialysis compare to that of blood?
Lowe than you want in blood returning to body so it moves out in dialyzer
78
What are the contraindications for haemodialysis?
Failed vascular access
Heart failure due to machine decreasing preload
Coagulopathy
79
What complications arise as a result of haemodialysis?
Lines --> infection, thrombosis, venous stenosis
AVF --> thrombosis, bleeding, access failure, steal syndrome causing an ischaemic hand
CVS instability
Felling chronically unwell
Accumulation of co-morbidities
80
Does peritoneal dialysis require more or less supplementary Tx (additional tablets and injections) than haemodialysis?
Fewer
81
What are the advantages of permit penal dialysis?
Self-sufficient
Less fluid and food restrictions
Fairly easy to travel with
Renal function better preserved initially
82
What is in the diasylate fluid in peritoneal dialysis?
Sugar or polymer
83
What are the disadvantages of peritoneal dialysis?
Frequent daily exchanges or overnight
Responsibility
No days off from illness
84
What are the contraindications for peritoneal dialysis?
Failure of peritoneal membrane e.g. due to scar from surgery
Adhesions, hernia, stoma
Pt or carer cannot connect/disconnect
Obese or large muscle mass due to reduced SA/volume
85
What complications are associated with peritoneal dialysis?
```
Peritonitis (typically experienced once ever 20 months)
Site infections
Ultrafiltration failure
Leaks into scrotum or diaphragm
Development of hernia
```
86
What is the difference between continuous ambulatory peritoneal dialysis and ambulatory peritoneal dialysis?
Continuous = 4-5 bags per day whereas other is overnight
87
What are the three different methods of kidney transplant currently available?
Live donor
Deceased after brain death (DBD)
Deceased after circulatory death (DCD/non-heart beating)
88
What are the advantages of kidney transplant for renal replacement therapy?
Decreased mortality and morbidity in comparison to dialysis
| Better QoL
89
What are the disadvantages of kidney transplant as a renal replacement therapy?
Peri-operative risk (mortality highest for 3 months after)
Malignancy risk
Infection risk
Diabetes and hypertension risk from additional medication required
90
Describe the process of kidney transplant.
Pt on waiting list --> accrues points based on age and waiting time --> tissue match by blood group(ABO) and MHC class I(HLA)--> attach new kidney to iliac arteries
91
What morbidity does transplant medication cause due to its side effects?
```
Diabetes
Hypertension
GI ulceration
Decreased WCC and platelets
Steroid S/E
```
92
Which type of kidney transplant has the best average transplant life?
Live related donor
93
What is the average transplant life for a DCD kidney transplant?
94
What is the average transplant life for a DCD kidney transplant?
95
How long does dialysis prolong life for in pts >70 y.o. with ESRD and significant CVD co-morbidities?
~2 years
96
Why do some pts >70 y.o. with ESRD and significant co-morbidities choose not to have dialysis?
Can survive a substantial length of time (although
97
Which co-morbidities confer a particularly poor outcome for elderly dialysis pts?
CVD
98
How does the mortality of ERSD pts compare to age matched pts without ERSD?
It is higher
99
When do pts die from ERSD?
If dialysis access is not possible otherwise CVD cause in dialysis or malignancy in transplant pts
100
What is the average life expectancy for a pt aged 25-29 with incident ERSD?
18 years from diagnosis
101
What is the average life expectancy for an incident ERSD pt aged 75 years?
3 years from diagnosis
102
How does the mortality rate of RRT pts compared to an age matched population compare between pts aged 30-34 and 85+?
```
30-34 = 25x greater
85+ = 2.7x greater
```
103
How long is the typical wait for a suitable kidney transplant?
3 years for deceased donor but longer for ethnic minorities
