19 - Care of the Renal Patient Flashcards Preview

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Flashcards in 19 - Care of the Renal Patient Deck (45):
1

What are the three types of renal failure?

Pre renal – (volume, renal artery stenosis)

Intrinsic – (toxins, infection, genetic)

Post renal – (stone)

2

What can cause acute renal failure?

- Toxins (nsaids, etoh, anti-freeze)
- Dehydration/fluid (shock)
- Rhabdo
- Infection
- Trauma
- CHF
- Stones

3

What can cause chronic renal failure?

***

- DM***
- HTN***
- CHF
- Autoimmune
- Infection (HIV)
- Inflammation (post-strep)***
- Polycystic kidney (#1 genetic; 6-8% dialysis)
- Drugs/toxins

4

Describe the incidence of chronic renal failure

- Number of people with CRF has more than doubled since 1990
- 54% of that increase not due to DM or HTN

5

What are the risks to getting renal disease?

**** TEST QUESTION ****

- DM
- Smoking
- HTN
- Obesity
- Cholesterol
- African/Eastern
- FMHx
- >65 y/o

6

Describe the increase in hospitalizations due to kidney disease

CDC – hospitalizations from kidney disease 4X 2005 compared to 1980

7

Why is hospitalization a big risk for new renal failure?

- 1% admitted to hospital dx RF
- 2 - 5% get ARF, double mortality
- Use of contrast
- Drugs (NSAIDS and ABX)
- Sepsis
- Surgery
- Hypo perfusion

8

Describe diabetes and renal failure

- 25-40% of type 1 (longer disease)
- 5-15% of type 2

9

Describe the renal disease implications for the lower extremities

**** TEST QUESTION ****

- Muscle infarct
- Osteoporosis/osteopenia
- Poor microcirculation
- Increased fx risk
- Tendon rupture
- ESRD – amputation 10X risk (2/3 of these amputations die within 1st year)

10

What type of history is suspicions for RF

- DM
- HTN
- Autoimmune DZ
- Age
- Family history
- Meds

11

Describe the ROS that hints toward renal disease

- Change in urination
- Neuropathy
- Unexplained FX
- LE edema
- SOB
- Fatigue
- N/V
- Itching

12

What does renal disease do to the bone?

*** TEST QUESTION ***

- Phosphorus and calcium inversely related
- RF leads to high phosphate
- Pulls calcium out of the bone

13

What in the physical exam could make you suspicious of renal disease?

- HTN
- Ascites
- LE edema
- Pulmonary crackles
- Rashes

14

What in the lab results could make you suspicious of renal disease?

- BUN/Cr.
- Increased K (some rare types low K)
- Increased Phos
- Decreased Ca
- Anemic

15

What can you do as a doctor to protect the patient's kidneys?

**** TEST QUESTION ****

- Prevent hypotension during surgery (limit time of surgery when possible)
- Prevent hypovolemia
- Avoid nephrotoxic medicines
- Encourage hypertension and diabetic treatment compliance
- Encourage to quit smoking

16

What meds are hard on the kidneys?

- NSAIDS
- Contrast (CT) - don't mix contrast and metformin
- Certain antibiotics
- Diuretics
- Certain diabetic meds

17

Describe the NSAID evils

- Can lead to resistant HTN
- Decreases prostaglandins (vasodilating)
- Increases systemic resistance
- Decreases Na excretion
- In RA, 8-27% increase in Cr. Over NML
- CHF

Need to do Cr checks if long term use

18

Describe NSAIDs and hypertension

- Can block some of the effects of diuretics, Beta Blockers and others
- Normal healthy people adjust

NSAIDs are vasoconstrictors

19

What meds clear slowly with renal failure?

*** TEST QUESTION ***

- Insulin
- Narcotics
- Benzos
- Some ABX

**********

20

Describe aminoglycosides and kidney failure

- Build up in proximal tubules 10 x serum level
- Can cause renal problems in 20% after 5-7 days
- Monitor levels
- Good news is these ABX are now used less

21

Describe the use of other antibiotics in kidney failure

- Cr clearance decides freq/dose
- Hard on kidneys – FQ, Bactrim
- Easy – PCN based, cephalosporins

22

Describe kidney damage due to contrast

*** TEST QUESTION***

- Cause unclear – hypo-perfusion or direct toxicity
- Higher risk in renal compromised, nephrotoxic drugs, dry
- 48 hours after contrast (recent change)
- Hydrate
- Pre-medicate Mucomyst
- Stop metformin 2 days past contrast (can stop prior if know before-hand)

23

Describe ACE inhibitors and renal protection

- Very renal protective, but we stop them during times of decreased renal function
- If someone put on ACE and Cr increases >30% look for pre-renal issue

24

Describe acute tubular necrosis

- Tubes connect the glomeruli
- Very metabolically active; sensitive to low fluid/O2
- Ischemic – hypotension, sepsis, prerenal, hypovolemia
- Nephrotoxic – aminoglycosides (gent), NSAIDS, cancer TX, contrast, rhabdo

25

What do we see in acute tubular necrosis?

- Increase in BUN, Cr
- Brown, granular casts
- Take off nephrotoxic meds
- Usually resolves 1-3 weeks

26

What is acute interstitial nephritis?

- Tissue around glomeruli and tubules get inflamed
- Usually allergic rxn to meds or infection
- PCN, NSAIDS, post strep, sarcoid

27

Describe the diagnosis and treatment of acute interstitial nephritis

- Dx – biopsy; sometimes eosinophils in urine
- TX – actually responds to steroids

28

How do you monitor renal function?

- UA
- Urine microalbumin (in diabetics, nephrotic)
- Creatinine, BUN
- Creatinine clearange (age, muscle mass)

29

Describe the use of dialysis

- 3-4 hours 3x/week
- Fatigue before and after; feel good day after
- Low NA, low protein, low fluid diet
- Cost - $90,000/year

30

What meds are dialysis patients on?

- Lasix
- BP meds
- Multivitamins, Ca supplements
- Epogen (RBC production)
- Phosphate binders
- Fe supplements

31

Describe dialysis and fracture risk

- 104 people on dialysis for 1 or more year
- 52% had low trauma fracture
- 69% had osteopenia by DEXA
- Not always related

32

Describe dialysis and nerve damage

- Some studies show decreased nerve conduction in LE, not in UE
- Peripheral neuropathy

33

Describe the mortality rates for renal transplant

- Mortality rate 8% year for cadaver recipients; 4% year for live recipients
- 12,000-14,000/yr done
- 1 yr graft survival 86% cadaver; 92% live
- HLA testing now done if >1 donor; blood type only
- Ave cost was $282,000 (2014 if done in US) – …break even about 4 years from dialysis

34

What is the risk of donating a kidney

- Unknown
- Mayo has done 5,000 in MN - no deaths
- Creatinine should end up b/t pre-surgery and just post surgery levels; varies
- Remaining kidney enlarges to adjust (is that okay???)

35

Give updated information on donation of kidneys

- ESRD – 15 yrs. post donation 11X higher (if related) and 7X higher 7 year out in another study
- Handful of deaths
- Systolic BP increases about 10 points a few years out
- Cardiac enzymes change immediately
- Bone loss
- Kidney hypertrophies

36

What did John Hopkins say about donors?

“Several recent studies, however, have shown that donors tend to do as well or better than the general population in regard to long term medical complications.”

37

What is the risk of being a kidney donor recipient?

- 40 X rate of cancer first year
- Infection; 75% 1st year
- Aseptic necrosis of bone

38

Describe the decreased wait time and complications for transplants over seas

- UCLA looked at transplant done overseas compared to those done at their facility
- 1st yr rejection (30% vs 12% here)
- Infection requiring hospitalization (27% vs 9% here)

39

In US, one of the major cause of kidney rejection?

Recipients can’t afford anti-rejection meds.

40

What will be done following transplant?

- BP meds
- Steroids
- Cellcept (decreases B and T proliferation)
- Cyclosporine
- Yearly biopsies; frequent blood draws

41

Case 1

65 y/o male comes to ER at 0200 in acute CHF

On dialysis, no kidneys (cancer)

42

What does this patient need?

Dialysis

43

Case 2

45 y/o male in head-on MVC. c/o
- R upper leg pain
- 1 yr following kidney transplant

44

What do you need to know about distracting injuries

- He only complained about leg (femur fx)
- Multiple fractures in foot as well
- NEED to remember that distracting pain will cover up other pain
- Repeat secondary surveys are important after trauma

45

Summary

- Be protective of the kidneys
- Monitor their function
- Treat renal patients similarly to diabetics
- Be aware of medicines and renal function