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Renal Pathology > Renal Replacement Therapy > Flashcards

Renal Replacement Therapy Flashcards

1
Q

Functions of the kidneys

A 
Excretion of nitrogenous waste products
Maintenance of acid and electrolyte balance
Control of BP
Drug metabolism and disposal 
Activation of vit D
Production of erythropoietin
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2
Q

Definition of end stage renal disease

A

Irreversible damage to a persons kidney so severely affecting their ability to remove or adjust blood wastes that, to maintain life, he or she must have either dialysis or a kidney transplant

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3
Q

Until what stages of CKD may the patient be asymptomatic?

A

4 or 5

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4
Q

What is the syndrome of advanced CKD called?

A

Uraemia

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5
Q

What is the earliest cardinal symptom of uraemia?

A

Malaise and fatigue

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6
Q

What is renal replacement therapy (RRT)?

A

The means by which life is sustained in patients suffering from end-stage renal disease

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7
Q

When is RRT usually indicated?

A

eGFR < 10ml/min

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8
Q

Types of RRT

A

Renal transplant
Haemodialysis
Peritoneal dialysis
Conservative kidney management

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9
Q

Types of PD

A

Continuous ambulatory peritoneal dialysis (CAPD)

Intermittent peritoneal dialysis

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10
Q

Definition of dialysis

A

A process by which the solute composition of solute A, is altered by exposing solution A to a second solution B, through a semipermeable membrane

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11
Q

Pre-requisites for dialysis

A

Semipermeable membrane
Adequate blood exposure to the membrane
Dialysis access
Anticoagulation in haemodyalsis

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12
Q

What is the semipermeable membrane in haemodialysis?

A

Artificial kidney

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13
Q

What is the semipermeable membrane in PD?

A

Peritoneal membrane

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14
Q

How does adequate blood exposure to the membrane occur in HD?

A

Extracorpeal blood

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15
Q

How does adequate blood exposure to the membrane occur in PD?

A

Mesenteric circulation

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16
Q

What type of dialysis access is used in haemodyalsis?

A

Vascular

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17
Q

What type of dialysis access is used in PD?

A

Peritoneal

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18
Q

What must be given in haemodialysis?

A

Anticoagulation

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19
Q

Dialysis access in HD

A 
Permanent;
- AV fistula
- AV prosthetic graft 
Temporary 
- tunnelled venous catheter
- temporal venous catheter
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20
Q

What restrictions do dialysis patients have?

A

Fluid restriction

Dietary restriction

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21
Q

What is the fluid restriction of dialysis patients dictated by?

A

Residual urine output

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22
Q

What dietary restrictions are in place for haemodialysis patients?

A

Potassium
Sodium
Phosphate

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23
Q

How does PD work?

A

A balanced dialysis solution is instilled into the peritoneal cavity via a tunnelled, cuffed catheter, using the peritoneal mesothelium as a dialysis membrane
After a swell time the fluid is drained out and fresh dialysate is instilled

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24
Q

What does the PD fluid contain?

A

Dialysate contains a balanced concentration of electrolytes

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25
Q

In PD, what is the most common osmotic agent for ultrafiltration of fluid?

A

Glucose

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26
Q

Complications of PD

A 
Exit site infection 
Tunnel infection 
PD peritonitis 
Ultrafiltration failure
Encapsulating peritoneal sclerosis
Tube malfunction 
Abdominal wall herniae
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27
Q

Causative organisms of PD peritonitis and their origins

A

Gram +ve = skin contaminant
Gram -ve = bowel origin
Mixed; suspect complicated peritonitis e.g. perforation

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28
Q

Indications for dialysis in ESRD

A 
Advanced uraemia (GFR 5-10ml)
Severe acidosis (bicarbonate < 10mmol/l)
Treatment resistant hyperkalaemia (K>6.5mmol/l)
Treatment resistant fluid overload
Nephrologists judgement
29
Q

What is the usual fluid restriction in HD?

A

500-800ml/24 hours intake

30
Q

What does intake allowed =?

A

Urine output + insensible losses

31
Q

Why is there a more liberal intake of fluid allowed in PD compared to HD?

A

As continuous ultrafiltration is often achieved

32
Q

Complications of HD

A 
CVS problems
- intra-dialytic hypotension and cramps
- arrhythmias 
Coagulation 
- clotting of vascular access 
- heparin related problems 
Allergic reactions to dialysers and tubing
Catastrophic dialysis accidents (rare)
33
Q

What is the most important factor in choosing modality of dialysis?

A

Patient choice

34
Q

Where is a transplanted kidney placed?

A

Into the iliac fossa and anastomosed to the iliac vessels

35
Q

What happens to the native kidneys?

A

They remain in situ

36
Q

Indications for a native nephrectomy

A

Size (polycystic kidneys)

Infection (chronic pyelonephritis)

37
Q

Why must the donor kidney be preserved?

A

Minimises oedema
Preserves the integrity of the tissues
Buffers free radicals

38
Q

Complications of transplant

A 
Vascular
- bleeding
- arterial and venous thrombosis
- lymphocele
Ureteric - urine leak 
Infections
39
Q

What immunosuppressive agents can be used in kidney transplant?

A 
Corticosteriods
Calcineurin inhibitors (TACROLIMUS, CYCLOSPORIN)
Anti-proliferatives
- mycophenolate mofetil 
- azathioprine 
mTOR inhibitors
- sirolimus 
Costimulatory signal blockers - belatacept 
Depleting agents
- basiliximab
- rituximab
40
Q

S/Es of corticosteriods

A 
HTN
Hyperglycaemia
Infections
Bone loss
GI bleeding
41
Q

S/Es of tacrolimus

A

Hyperglycaemia
AKI
Tremor

42
Q

S/Es of cyclosporin

A

Hirsutism
AKI
HTN
Gout

43
Q

Immunosuppression protocols in kidney transplant

A 
Induction = basiliximab 
Maintenance = tacrolimus + mycophenolate + steroids
44
Q

S/Es of mycophenolate

A

Cytopenia

GI upset

45
Q

Types of donors

A

Deceased donors

Living donors

46
Q

Types of deceased donors

A

Donation after brain death (DBD)

Donation after cardiac death (DCD)

47
Q

Types of living donors

A 
Living related 
Living unrelated
- spousal 
- altruistic 
- paired/pooled
48
Q

Brain death criteria

A 
Coma
Unresponsive to stimuli 
Apnoea off ventilator (with oxygen) despite build up of CO2
Absence of cephalic reflexes 
Body temp above 34C
Absence of drug intoxication
49
Q

What are the cephalic reflexes?

A 
Pupillary 
Oculocephalic
Oculovestibular (caloric)
Corneal 
Gag
50
Q

Complications after renal transplant

A 
Rejection 
CVS 
- CRF
- HTN
- Hyperlipidaemia 
- PT diabetes
Infective
Malignancy 
- skin 
- lymphoma
- solid cancers
51
Q

Types of acute rejection

A

Hyperacute rejection

Acute rejection

52
Q

What is hyperacute rejection?

A

Pre-existing alloreactivity to donor

53
Q

Pathology of acute rejection

A 
T cell mediated rejection 
- tubulointerstital (Banff I)
- arteritis / endothelialitis (Banff II)
- arterial fibroid necrosis (Banff III)
Acute antibody mediated rejection (ABMR)
- ATN-like (Banff I)
- capillaries and or glomerular inflammation (Banff II)
- arterial inflammation (Banff III)
54
Q

What does a T cell mediated rejection consist of?

A

Lymphocytic infiltration
Tubulitis
Endarteritis
Endotherliathisis

55
Q

What does an antibody mediated rejection consist of?

A 
Microvascular inflammation 
- neutrophil infiltration 
- glomeruli 
- peritubular capillaries 
Donor specific antibodies 
Positive C4d peritubular capillaries
56
Q

What is the most important transplant related infection?

A

Cytomegalovirus

57
Q

What % of transplant recipients are affected by CMV, despite prophylaxis therapy?

A

8%

58
Q

How do transplant recipients get CMV?

A

Transmission from donor tissue

Reactivation of latent virus

59
Q

What does CMV cause?

A 
Pneumonitis
Retinitis
Gastroenteritis
Colitis
Nephritis
60
Q

Clinical manifestation of the BK virus in renal transplantation

A

Ureteral stenosis
Interstitial nephritis
ESRF

61
Q

Risk factors for BKAN (BK virus)

A 
Intensity of immunosuppression 
Patient
- older
- male
- white
- DM
- negative BKV serostatus (paediatric recipients)
Graft injury 
HLA mismatches 
Ureteral stents 
Viral determinants
- changes in epitopes of viral capsid protein VP-1
62
Q

What % of patients with the BK virus loose their graft?

A

45-80%

63
Q

Treatment of BK virus

A

Reduce immunosuppression
Antiviral therapy
- cidofovir +/- IVIG
- leflunomide

64
Q

What type of malignancy has the highest risk of developing after renal transplantation?

A

Non melanoma skin
Kapsoi sarcoma
Non hodgkins lymphoma

65
Q

What is the best way to treat end stage renal disease?

A

Kidney transplantation

66
Q

How long does it take for an AV fistula to develop?

A

6 - 8 weeks

67
Q

What is the most common and important viral infection that develops in solid organ transplant patients?

A

CMV

68
Q

Treatment for CMV

A

Ganciclovir

69
Q

What is the preferred mode of access for haemodialysis?

A

AV fistula

Renal Pathology (13 decks)

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