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Semester 3 > Urinary Session 11 > Flashcards

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

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2
Q

What can be used in addition to eGFR to assess renal function?

A

Albumin-creatinine ratio

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3
Q

What proportion of nephrons need to be working in a kidney in order for renal function to be sufficient?

A

2%

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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
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5
Q

What are the commonest causes of CKD?

A

Diabetes

Idiopathic

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6
Q

Which cause of CKD gives rise to an exception to the common histological appearance of CKD?

A

Polycystic kidney

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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

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8
Q

How does the incidence of CKD change relative to staging?

A

Decreases as staging increases

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9
Q

What is associated with CKD pts who inexorably worsen?

A

CVS morbidity and mortality, often before GFR decrease requires dialysis

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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

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11
Q

When does mortality start to increase in CKD?

A

Once eGFR has decreased by 25%

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12
Q

What is chronic kidney disease?

A

Irreversible +/- progressive loss of renal function over a period of months to years

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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
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14
Q

What is proteinuria proportional to in CKD?

A

Development of end-stage renal disease therefore more protein –> steeper decline in eGFR

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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

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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

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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)

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18
Q

Can eGFR be used to assess a child’s renal function?

A

No, adults only

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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
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20
Q

When is the kidney biopsied in CKD?

A

If kidneys are normal size and there is no obvious CKD cause

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21
Q

What are the possible complications of CKD?

A

Metabolic acidosis
Normocytic and normochromic anaemia
Metabolic bone disease

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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

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23
Q

What are the consequence of metabolic acidosis in CKD?

A

Muscle function impairment
Decreased bone mass
Worsened renal function decline

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24
Q

What is the Tx for metabolic acidosis in CKD?

A

Oral NaHcO3- tablets

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25
Q

How does CKD cause anaemia?

A

Decreased EPO production and increased resistance –> decreased RBC survival –> blood loss

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26
Q

What is renal osteodystrophy?

A

Sclosis of vertebral end plates and erosion of terminal phalanges

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27
Q

How does CKD cause metabolic bone disease?

A

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

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28
Q

How is metabolic bone disease in CKD treated?

A

Supplements

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29
Q

What potentially modifiable risks can be targeted in management of CKD?

A 
Smoking
Obesity
Lack of exercise
Tx DM and hypertension
In proteinuria use ACEI/ARBs and consider lipid lowering Tx
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30
Q

When is renal replacement therapy used to manage CKD?

A

Native renal function decreases and can no longer support health

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31
Q

What symptoms indicate renal replacement therapy with dialysis in CKD?

A 
Uraemic symptoms
Acidosis
Pericarditis
Fluid overload
Hyperkalaemia
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32
Q

What is end-stage renal failure?

A

When death is likely without renal replacement therapy

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33
Q

What is the numerical definition of ESRF?

A

eGFR

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34
Q

What are the S/S of ESRD?

A 
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
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35
Q

What causes an increase in number of infections in ESRD?

A

Impaired cellular and humoral immunity

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36
Q

What is the effect of CKD in water/salt handling when GFR is small but the solute load is the same?

A

Osmotic diuresis due to impaired maximum concentrating ability and reduced response to ADH –> nocturia

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37
Q

What is the effect of CKD on renal water/salt handling when the volume of filtrate is reduced?

A

Impaire ability of kidney to excrete substances –> decrease in max urine volume

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38
Q

Why do 80-85% of CKD pts have altered water/salt handling?

A

They are hypertensive and are taking anti-hypertensives/diuretics/fluid restricted

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39
Q

Why might muscle or bone pains be felt in acid abase balance and electrolyte disturbances due to CKD?

A

Acidosis –> hyperphosphataemia and decreased 1-alpha-calcidiol –> bone breakdown
Acidosis –> muscle wasting

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40
Q

If there a definitive threshold in the accumulation of waste products and onset or uraemic symptoms?

A

No

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41
Q

Why do most drugs need dose altering in CKD/ESRD pts?

A

Decreased metabolism +/- elimination

Increased sensitivity without impairment of elimination –> increased likelihood of S/E

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42
Q

What are the advantages of using haemodialysis for renal replacement therapy?

A

Less responsibility for Tx

Days off between dialysis sessions so can forget illness

43
Q

What are the disadvantages of haemodialysis Tx?

A

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
Q

Why is home/nocturnal haemodialysis considered better than in hospital?

A

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
Q

Describe the process of haemodialysis.

A

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
Q

How does the K+ concentration of diasylate fluid in haemodialysis compare to that of blood?

A

Lowe than you want in blood returning to body so it moves out in dialyzer

47
Q

What are the contraindications for haemodialysis?

A

Failed vascular access
Heart failure due to machine decreasing preload
Coagulopathy

48
Q

What complications arise as a result of haemodialysis?

A

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
Q

Does peritoneal dialysis require more or less supplementary Tx (additional tablets and injections) than haemodialysis?

A

Fewer

50
Q

What are the advantages of permit penal dialysis?

A

Self-sufficient
Less fluid and food restrictions
Fairly easy to travel with
Renal function better preserved initially

51
Q

What is in the diasylate fluid in peritoneal dialysis?

A

Sugar or polymer

52
Q

What are the disadvantages of peritoneal dialysis?

A

Frequent daily exchanges or overnight
Responsibility
No days off from illness

53
Q

What are the contraindications for peritoneal dialysis?

A

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
Q

What complications are associated with peritoneal dialysis?

A 
Peritonitis (typically experienced once ever 20 months)
Site infections
Ultrafiltration failure
Leaks into scrotum or diaphragm
Development of hernia
55
Q

What is the difference between continuous ambulatory peritoneal dialysis and ambulatory peritoneal dialysis?

A

Continuous = 4-5 bags per day whereas other is overnight

56
Q

What are the three different methods of kidney transplant currently available?

A

Live donor
Deceased after brain death (DBD)
Deceased after circulatory death (DCD/non-heart beating)

57
Q

What are the advantages of kidney transplant for renal replacement therapy?

A

Decreased mortality and morbidity in comparison to dialysis

Better QoL

58
Q

What are the disadvantages of kidney transplant as a renal replacement therapy?

A

Peri-operative risk (mortality highest for 3 months after)
Malignancy risk
Infection risk
Diabetes and hypertension risk from additional medication required

59
Q

Describe the process of kidney transplant.

A

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
Q

What morbidity does transplant medication cause due to its side effects?

A 
Diabetes
Hypertension
GI ulceration
Decreased WCC and platelets
Steroid S/E
61
Q

Which type of kidney transplant has the best average transplant life?

A

Live related donor

62
Q

What is the numerical definition of kidney failure?

A

eGFR

63
Q

How long does dialysis prolong life for in pts >70 y.o. with ESRD and significant CVD co-morbidities?

A

~2 years

64
Q

Why do some pts >70 y.o. with ESRD and significant co-morbidities choose not to have dialysis?

A

Can survive a substantial length of time (although

65
Q

Which co-morbidities confer a particularly poor outcome for elderly dialysis pts?

A

CVD

66
Q

How does the mortality of ERSD pts compare to age matched pts without ERSD?

A

It is higher

67
Q

When do pts die from ERSD?

A

If dialysis access is not possible otherwise CVD cause in dialysis or malignancy in transplant pts

68
Q

What is the average life expectancy for a pt aged 25-29 with incident ERSD?

A

18 years from diagnosis

69
Q

What is the average life expectancy for an incident ERSD pt aged 75 years?

A

3 years from diagnosis

70
Q

Why might muscle or bone pains be felt in acid abase balance and electrolyte disturbances due to CKD?

A

Acidosis –> hyperphosphataemia and decreased 1-alpha-calcidiol –> bone breakdown
Acidosis –> muscle wasting

71
Q

If there a definitive threshold in the accumulation of waste products and onset or uraemic symptoms?

A

No

72
Q

Why do most drugs need dose altering in CKD/ESRD pts?

A

Decreased metabolism +/- elimination

Increased sensitivity without impairment of elimination –> increased likelihood of S/E

73
Q

What are the advantages of using haemodialysis for renal replacement therapy?

A

Less responsibility for Tx

Days off between dialysis sessions so can forget illness

74
Q

What are the disadvantages of haemodialysis Tx?

A

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
Q

Why is home/nocturnal haemodialysis considered better than in hospital?

A

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
Q

Describe the process of haemodialysis.

A

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
Q

How does the K+ concentration of diasylate fluid in haemodialysis compare to that of blood?

A

Lowe than you want in blood returning to body so it moves out in dialyzer

78
Q

What are the contraindications for haemodialysis?

A

Failed vascular access
Heart failure due to machine decreasing preload
Coagulopathy

79
Q

What complications arise as a result of haemodialysis?

A

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
Q

Does peritoneal dialysis require more or less supplementary Tx (additional tablets and injections) than haemodialysis?

A

Fewer

81
Q

What are the advantages of permit penal dialysis?

A

Self-sufficient
Less fluid and food restrictions
Fairly easy to travel with
Renal function better preserved initially

82
Q

What is in the diasylate fluid in peritoneal dialysis?

A

Sugar or polymer

83
Q

What are the disadvantages of peritoneal dialysis?

A

Frequent daily exchanges or overnight
Responsibility
No days off from illness

84
Q

What are the contraindications for peritoneal dialysis?

A

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
Q

What complications are associated with peritoneal dialysis?

A 
Peritonitis (typically experienced once ever 20 months)
Site infections
Ultrafiltration failure
Leaks into scrotum or diaphragm
Development of hernia
86
Q

What is the difference between continuous ambulatory peritoneal dialysis and ambulatory peritoneal dialysis?

A

Continuous = 4-5 bags per day whereas other is overnight

87
Q

What are the three different methods of kidney transplant currently available?

A

Live donor
Deceased after brain death (DBD)
Deceased after circulatory death (DCD/non-heart beating)

88
Q

What are the advantages of kidney transplant for renal replacement therapy?

A

Decreased mortality and morbidity in comparison to dialysis

Better QoL

89
Q

What are the disadvantages of kidney transplant as a renal replacement therapy?

A

Peri-operative risk (mortality highest for 3 months after)
Malignancy risk
Infection risk
Diabetes and hypertension risk from additional medication required

90
Q

Describe the process of kidney transplant.

A

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
Q

What morbidity does transplant medication cause due to its side effects?

A 
Diabetes
Hypertension
GI ulceration
Decreased WCC and platelets
Steroid S/E
92
Q

Which type of kidney transplant has the best average transplant life?

A

Live related donor

93
Q

What is the average transplant life for a DCD kidney transplant?

A
94
Q

What is the average transplant life for a DCD kidney transplant?

A
95
Q

How long does dialysis prolong life for in pts >70 y.o. with ESRD and significant CVD co-morbidities?

A

~2 years

96
Q

Why do some pts >70 y.o. with ESRD and significant co-morbidities choose not to have dialysis?

A

Can survive a substantial length of time (although

97
Q

Which co-morbidities confer a particularly poor outcome for elderly dialysis pts?

A

CVD

98
Q

How does the mortality of ERSD pts compare to age matched pts without ERSD?

A

It is higher

99
Q

When do pts die from ERSD?

A

If dialysis access is not possible otherwise CVD cause in dialysis or malignancy in transplant pts

100
Q

What is the average life expectancy for a pt aged 25-29 with incident ERSD?

A

18 years from diagnosis

101
Q

What is the average life expectancy for an incident ERSD pt aged 75 years?

A

3 years from diagnosis

102
Q

How does the mortality rate of RRT pts compared to an age matched population compare between pts aged 30-34 and 85+?

A 
30-34 = 25x greater
85+ = 2.7x greater
103
Q

How long is the typical wait for a suitable kidney transplant?

A

3 years for deceased donor but longer for ethnic minorities

Semester 3 (50 decks)

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