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GI, liver, kidney > Dialysis > Flashcards

Dialysis Flashcards

1
Q

How is a fistula made

A

Artery attached to vein. High pressure arterial blood -> vein enlarges and thickened wall, allows two large bore cannulas to be placed on a regular basis

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2
Q

Why is fistula preferred for haemodialysis

A

Lower infection risk that neck line

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3
Q

how often do you have haemodialysis

A

4 hours 3 x a week

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4
Q

Types of RRT

A

Intermittent haemodialysis
Continuous haemofiltration
Continusous haemodialysis
Peritoneal dialysis

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5
Q

What is continious therapy used for

A

AKI when improved benefits over intermittent therapy - improved tolerability as result slower removal of solute and water

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6
Q

How does haemodialysis work

A

Blood -> dialysis machine which has a membrane so solutes diffuse between dialysate fluid and blood

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7
Q

How long does it take for an AV fistula to become usable

A

6-8 weeks

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8
Q

Complications of haemodialysis

A

Access related - bactaraemia -> endocarditis, discitis
Venous stenosis
Access failure
Haemodynamic instability
N+V
Headahce
Cramps, esp leg
Reactions to dialysis membranes

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9
Q

How does peritoneal dialyisis

A

Diasylate fluid -> abdominal cavity,filtration across peritoneal membrane, after several hours used fluid drained

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10
Q

What patients are not suitable for peritoneal dialysis

A

Functional peritoneal membrane
eg no prev intra abdominal pathology - prev peritonitis, surgery, adhesions

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11
Q

What is Continuous ambulatory peritoneal dialysis (CAPD)

A

Manual dialysate exchanges are typically performed 3-5 x a day
20-40 minutes per exchange

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12
Q

Automated dialysis what is

A

machine performs exchanges overnight
12 hours

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13
Q

Complications of peritoneal dialysis

A

Bacterial/fungal peritonitis
Catheter problems: infection, blockage, kinking, leaks, displacement (more likely if patient becomes constipated)
Weight gain
Worsening glycaemic control in patients w diabetes
failure of peritoneal membrane requiring switch to haemodialysis
Encapsulating peritoneal sclerosis

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14
Q

Cloudy peritonitis peritoneal fluid means

A

Peritonitis
Intraperitoneal disease - appendicitis, cholecystis, bowel ischaemia
Retroperitoneal disease - pancreatitis, renal cell carcinoma
Drugs - vancomycin, amphotericin B
Allergic reaction - increased eosinophils

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15
Q

Bloody haemodialysis drained fluid

A

Coagulopathy
Retrograde menstruation
Ovulation
Strenous exercise
Ovarian cyst rupture
Adhesions
Catheter ass trauma

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16
Q

Chylous peritoneal fluid drainage (White)

A

High triglycerides
Lymphatic obstruction
Trauma
Abdominal lymphomes
Pancreatitis
Drugs - CCB

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17
Q

Gold standard for RRT

A

Renal transplant

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18
Q

How does renal transplant work

A

Old kidneys left in place
L or R iliac fossa

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19
Q

Benefits of transplantation

A

obviates the
need for dialysis, can ameliorate anaemia and renal bone disease
and improves quality of life and long-term survival.

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20
Q

Contraindications to transplantation

A

Active or recent malignancy
Active infection
Significant comorbidity

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21
Q

Complications of renal transplantation

A

Operative comps
Stenosis of graft artery or ureter
Side effects from immunosupressive therapy Opportunisitic CMV
Malignancy
Recurrence of OG disease
Hyperacute graft rejection
Acute graft rejection
Chronic allograft rejection

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22
Q

Malignancy from renal transplantation

A

Epstein Barr virus -> non hodgkin B cell lymphomas, non melanoma skin cancers (squamous and basal)

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23
Q

Side effects of immunosupressive therapy

A

(nephrotoxicity + HPTN secondary to tacrolimus or ciclosporin)

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24
Q

hyeracute graft rejection

A

untreatable and should not occur if
appropriate cross-matching has been performed

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25
Q

How does acute graft present

A

Creatinine rise in 1st week to 3 months
Diagnosed by graft biopsy
Initial treat - IV steroids
All have some level of acute rejection

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26
Q

How does a chronic allograft nephropathy present

A

Multiple reasons
Doesn’t normally respond to increased immunosupression

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27
Q

Peritonitis signs

A

Abdominal pain varying severeity
Cloudy effluent
Vomitting, nausea, paralytic ileus, sometime bowel perforation
TREAT - intra peritoneal anitbiotics

28
Q

When considered for transplant

A

eGFR <15%
Within 6 months of dialysis
Medically fit
All tests done

29
Q

Basics of drug metabolism

A

Absorption
Distribution
Metabolism
Excretion

30
Q

Why is oral absorption reduced in kidney disease

A

Nephrotic/fluid overload -> oedema in gut
Uraemia - N+V
Reduced gut motility
Increased gut pH
Concurrent medication
Phosphate binders eg calcium acetate

31
Q

Gut motility in diabetes

A

Reduced - drugs stay in stomach longer

32
Q

Role of phosphate binders in kidnye disease

A
33
Q

Distribution of drugs how effected in kidney imapriemnt

A

Oedema - larger volume of distribution into water soluble compartment
Changes in hydration status
Long term malnutrition and muscle mass

34
Q

What are patients with CKD on long term dialysis more at risk of that effects drug distribution

A

Malnutrition -> reduced muscle mass -> reduced protein binding, reduced tissue bindinG OF DRUGS

35
Q

What drugs is metabolism slower for in CKD

A

Vitamin D
Insulin

36
Q

What is the problem with excretion in renal impairemnt?

A

Any drug predominantly excreted by the kidney will accumulate

37
Q

What does accumulation from impaired excretion of drugs cause?

A

Increased side effects
Increased toxic effects
Increased therapeutic effects

38
Q

What are aminoglycosides toxic to?

A

Tubular cells

39
Q

What drugs can directly cause acute intersitial nephritis

A

Trimethoprin, penicillins, vancomycin, NSAIDs

40
Q

What renal damage can immune modulators cause

A

Nehropathies
Tubular damage
Acute intersitial nephritis

41
Q

What drugs are indirectly renotoxic and why

A

Drugs that cause altered haemodynamics compromising renal perfusion eg ACEi/ARB, diuretics, vasodilators

42
Q

Ideal drugs for renally impaired

A

Not metabolised or excreted by kidneys
Wide therapeutic index
Few/benign side effects
Doesnt interact with other drugs
Not affected by hydration status
Low protein binding
Low Na content (will cause more oedema if not)
Low infusion volume

43
Q

Drugs to absolutely avoid in renal impairemnt

A

Preominantly renally excreted
Nephrotoxic
Serious dose related adverse effects
Narrow TI
not possible to monitor levels

44
Q

Theoretical eGFR for Different dialysis (function of kidney assumed)

A

150-200 druing, 0 in between (overall average <10)
5-10 peritoneal dialysis
15-25 - CVVH
30-40 CVVHDF

45
Q

CVVH mechanism of action

A

Continious - works by convection

46
Q

CKD supportive medications

A

Renal anaemia
Bone chemistry
Acid/base balance
Analgesia
Antidepressants
Extra vitamins
Laxatives

47
Q

Who is laxatives with CKD particuarly important in?

A

Peritoneal dialysis

48
Q

What drugs could be used for bone chemistry

A

Alfacalcidol, phosphate binders, cincalcet, etelcalcitide

49
Q

What medication used for acid base balance in CKD

A

Na bicarbonate

50
Q

What is renavit used in

A

Extra vitamins for haemodialysis intermittent patients

51
Q

What is the active form of vitamin D

A

Alfacalcidol - drug unaffected by dialysis

52
Q

statin risks with CKD on ITU

A

Risk of accumulation therefore increased risk of myopathy

53
Q

Why is calcium acetate required in dilaysis patients?

A

Phosphate is not removed in dialysis so needs to be removed seperately

54
Q

What happens if patient vitamin D intake is too high?

A

Hypercalcemia and hyperphosphatemia

55
Q

What happens to EPO dose on dialysis

A

Needs to be increased as less functioning kidney to produce hormone

56
Q

What can ACEi cause that is dangerous in a renal patient?

A

Hyperkalemia - less ability to be removed through kidneys, solely relying on dialysis

57
Q

Why are patients told to eat a low potassium diet if renal impairment on ACEis

A

ACEis can cause hyperkalemia

58
Q

Why is oxycodone used over morphine for pain relief in renal impairment

A

active metabolites of oxycodone less renotoxic than morphine
Still reduce dose if renal impairment worse

59
Q

Why can sodium bicarbonate be discontinued on dialysis

A

Given through dialysis machine rather than oral

60
Q

Drug factors in dialysis

A

Molecular weight
Protein binding
Water solubility
Absorption of drug molecule onto dialysis membrane (membrane or drug charged)

61
Q

Dialysis factors in drug dosing in RRT

A

Duration of dialysis
Flow rate - blood and dialysate
Type of membrane used - permeability

62
Q

How use creatinine clearnace on dialysis

A

don’t calculate on dialysis as not accurate - dose as if <10

63
Q

What consider when prescribing for every renal patient

A

Choice, starting dose, frequency (lower dose, less frequent as rule of thumb)
Adjust dose according to response
Monitor for toxicity
Back up dosage pescriptions with serum drug level monitoring where possible

64
Q

Hyperacute liver failure what is it

A

Jaudniced encephalopathy less than or = to one week after incident

65
Q

Biochemical picture in hyperacute liver failure

A

Significantly elevated PT
Low to mod rise in bilirubin
Marked increase INR
Rapid progression

66
Q
A

GI, liver, kidney (50 decks)

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