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Leila PACES > Abdomen > Flashcards

Abdomen Flashcards

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1
Q

Midline laparotomy scar in a renal tx patient?

A

SPKT (usually younger T1DM patients)

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2
Q

Side effects of immunosuppression in transplant patients

A

Tremor
Gum hypertrophy
Dyslipidaemia
HTN
Hypertrichosis (ciclosporin)
Diabetes (CNRI) - NODAT
Opportunistic infections
Skin cancer
Steroids: osteoporosis, easy bruising, cushingoid features, proximal myopathy, cataracts
MMF: GI symptoms

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3
Q

SE of chronic immunosuppression in general

A

Opportunistic infections
PTLD
Skin malignancies
Viral warts

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4
Q

Renal tx and hearing aids?

A

Alport’s syndrome

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5
Q

Renal tx scar, b/l ballotable kidneys and nephrectomy scar?

A

ADPKD

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6
Q

Non-scarring alopecia, oral ulcers, malar rush, young femal patient, CKD/renal tx?

A

SLE

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7
Q

Features on clinical exam of a patient with ESRD secondary to diabetic nephropathy

A

Finger prick marks
Free style Libra device
diabetic dermopathy
Foot ulcers/amputations

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8
Q

What are the main causes of ESRF?

A

Diabetic nephropathy
Hypertensive nephropathy
ADPKD
Glomerulonephritis

Drugs: cyclosporine, NSAIDs, aminoglycosides
Autoimmune: SLE, RA, GPA, eGPA
Reflux nephropathy / recurrent UTI
Alport’s syndrome

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9
Q

Order when presenting a transplant case

A

“This is a patient who has evidence of previous ESRD (Secondary to X if known) with a renal transplant as evidenced by a J-shaped scar in the RIF with an underlying firm, palpable, non-tender mass. The transplant appears to be functioning. Previous modes of RRT include X as evidenced by Y. There are/are not any signs of immunosuppressant toxicity. This patient does not appear clinically overloaded and there are no signs of suggestive of uraemia.

There were no specific signs pointing to a specific aetiology, possible differentials include…”

1) esrd +/- aetiology
2) transplant
3) evidence of above
4) tx functioning?
5) prev modes of RRT
6) Complications: immunosupp tox, fluid, uraemima
7) signs suggestive of aetiology

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10
Q

How would you like to complete your examination in a renal patient?

A

“To complete my examination I would like to measure the blood pressure, perform urinalysis and do a full fluid assessment”

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11
Q

Signs of graft failure

A

Reduced UO
Tenderness over graft
Fever
Features of uraemia
Increased fluid retention
Rise in creatinine

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12
Q

Nephrectomy indications in CKD pt

A

Room for new kidney
Recurrent infections of cysts / haemorrhage / pain

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12
Q

What to do if you see an AVF?

A

Inspect for recent needling, palpate for thrill, auscultate for bruit

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13
Q

If scar in iliac fossae but no palpable mass, cause?

A

Transplant nephrectomy or not working anymore (look for signs of active RRT)

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14
Q

What to look for in the face, neck and chest of a renal patient?

A

Corneal arcus (CVS risk, CNRIs)
JVP for fluid status
Scars in neck for lines
Parathyroidectomy scar ? tertiary hyperparathyroidism

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15
Q

WHy may a CKD patient have a horizontal scar in the anterior neck?

A

Parathyroidectomy from tertiary hyperparathyroidism

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16
Q

Modes of HD

A

AVF
AV graft
Tunneled CVs
Non-tunneled CVCs
(in order of preference)

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17
Q

Clinical signs which help determine adequacy of RRT

A

Asterixis (uraemic encephalopathy)
Volume status
Excoriations (pruritis from uraemia)
Tachypnoea (resp compensation from metabolic acidosis)
Pericardial rub (uraemic pericarditis)

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18
Q

Complications of ESRF

A

Renal anaemia
Tertiary hyperparathyroidism
Volume overload
Metabolic bone disease (renal osteodystrophy)
CVS risk
Acidosis
Uraemia complications: loss of appetite, encephalopathy, pericarditis
Electrolyte impairment (hyperkalaemia)

CRFHEALSU
CVS
Renal osteodystrophy (phosphate binders, activated vitamin D)
Fluid OD
HTN
Electrolyte disturbance
Acidosis, Anaemia
Leg restlessness
Sensory neuropathy
Uraemia complications

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19
Q

Treatment for renal anaemia

A

Iron and EPO

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20
Q

Renal transplant complications

A

Early: acute graft dysfunction
Late: drug toxicity, immunosuppression SE, opportunistic infections, cancer, NODAT
Recurrence of original disease
CVS disease

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21
Q

What should renal tx patients be followed up for annually

A

Malignancy
CVS disease
drug toxicity

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22
Q

Indications for urgent dialysis

A

Acidosis, electrolytes (refractory hyperkalaemia), fluid overload, uraemia (pericarditis or encephalopathy), overdose/toxicity

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23
Q

At what stage refer pt for RRT?

A

Depends on kidney failure risk equation, NICE guidelines on urgency of referral based on their score

(generally CKD 4-5, eGFR <30 or rapidly progressive, ideally to be seen > 1 year prior to needing RRT)

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24
Complications of AV fistula
Infection Haemorrhage Thombosis Stenosis Aneurysm Steal syndrome High output cardiac failure Failure to form
25
How to differentiate between a kidney and a spleen on exam
Kidney: does not move with respiration Ballotable Can get above it Spleen Cannot get above it Notch Moves with respiration
26
What investigations would you do for renal tx pt coming in on the take?
Obs: BP, temp DRUG CHART FOR NEPHROTOXIC AGENTS BM Urine: dip for glucose, protein and blood VBG: Acidosis? electrolytes? Hb? ECG: ?Pericarditis (ST depression and saddle elevations) Bloods: FBC (renal anaemia, infection), UE, bone profile, hba1c, CRP, iron/b12/folate, vitamin D, PTH FUll septic workup if febrile Tacrolimus levels, ACR Viral: PCP, CMV, BK, EBV, Fungal markers, JC vius CXR: Fluid OD Imaging: transplant USS +/- doppler Special tests - Renal biopsy to investigate graft deterioration
27
Management of renal tx patients
MDT approach Patient education on risk factors, medication compliance, modifying CVS risk factors (smoking cessation), when to seek hospital support Sun screen Monitor for immunosuppressant toxicity Ensure attends cancer screening and skin cancer checks Acute presentations with infections to be treated as per sepsis guideliens Initiate RRT if graft function despite appropriate immunosuppression
28
standard immunosuppressant regimen for renal tx
CNI, MMF, steroido
29
Contraindications to renal tx
Active cancer Active drug use active infection Uncontrolled psychiatric disorder Obesity Lack of suitable donor Severe comorbidity
30
Examples of glomerulonephritis which cause ESRD
IgA, FSGS, membranous nephropathy
31
Which viruses to screen for in renal tx pts in hospital
CMV, BK, EBV, JC, HSV
32
Renal tx pt with sclerodactyly, bird beak nose, microstomia
Systemic sclerosis
33
Renal tx + rheumatoid hands, nodules
RA
34
Renal + liver tx
? CNI toxicity
35
Gum hypertrophy DDx
Drugs: ciclosporin Scurvy AML Familial
36
Assessment of a pt prior to renal transplant
Virology: CMV, Hepatitis, VZV, HIV ABO Anti-HLA antibodies HL DR > B > A Assess comorbidities (assess CVD)
37
Types of kidney donor
DBD DCD Live (Related and unrelated)
38
Types of rejection
Hyperacute (mins) Acute < 6mo Chronic > 6mo
39
General dialysis complications
CVS disease Malnutrition Infection Psychosocial Amyloidosis Renal cysts
40
What is steal syndrome?
Distal ischaemia on side of AVF
41
Which bloods to send for SLE?
ANA, C3,C4
41
Commonest cause of death in systemic sclerosis
Renal crisisW
42
What does a SS renal crisis constitute
Malignant HTN, acute renal failure Mx: ACEi
43
DDx bilateral renal enlargement
ADPKD Bilateral hydronephrosis Bilateral renal cell ca i.e. VHL Tuberous Sclerosis Amyloidosis
44
DDx unilateral renal enlargement
ADPKD Hydronephrosis Renal cell ca Renal hypertrophy
45
What may a renal bruit heard over a transplanted kidney suggest?
Renal artery stenosis
46
Serious SE of azathioprine
BM suppression (check TPMT levels prior to commencing)
47
Complications of ADPKD
Renal: Pain Infection of cysts Hypertension Cyst haemorrhage and rupture Extra-renal: Cysts elsewhere: spleen, liver, pancreas Berry aneurysms and stroke MVP, aortic root dilatation, dissection Colonic diverticulae
48
Neurological complication of CKD
Sensory neuropathy
49
Types of ADPKD and chromosomes
PKD 1 gene (Type 1) - Chr 16 (85%) PKD 2 gene (Type 2) - Chr 4
50
Name some renal cystic disordersA
ADPKD VHL TS
51
VHL genetics
Autosomal dominant, tumour suppressor gene
52
TS genetics
AD, TSC1 and TSC2
53
How may an ADPKD patient present? (renal signs/symptoms)
Pain Mass Recurrent UTI Macroscopic haematuria Proteinuria Renal failure/ CKD HTN Renal stones
54
Non-renal signs and symptoms in an ADPKD patient
Berry aneurysms/ SAH Cardiac complications: MVP, aortic root dilatation, aortic dissection Cysts elsewhere
55
ADPKD diagnostic classification name
Ravine Pei
56
Outline the Ravine Pei diagnostic classification of ADPKD
< 30 - 2 cysts in either kidney 30 - 59 2 cysts in each kidney > 60 - 4 cysts in each kidney
57
Diagnostic investigation for ADPKD
USS
58
Which mode of dialysis is avoided in ADPKD?
Peritoneal dialysis due to risk of infection
59
Extra renal features on examination of an ADPKD patient
Hemiparesis Liver cysts/ irregular liver edge Craniotomy scar Nephrectomy scars
60
Why may an ADPKD patient have loin pain?
Mass effect Renal stones Cyst infection, rupture, haemorrhage UTI
61
Which renal cystic conditions are at high risk of neoplastic transformation?
VHL and TS
62
Investigations for an ADPKD patient
History - FH, intracranial aneurysms, heart disease etc Obs - BP, urine dip and urinalysis ECG Bloods: FBC, UE, LFT, Bone profile (renal bone disease) Imaging: CXR (fluid OD), Renal USS Offer genetic testing
63
Management in ADPKD
MDT: nephrologist, specialist nurses, geneticists/counsellors, dietitian, GP Non-pharmacological: patient education, referral to support groups, dietary advice (low salt and protein), family genetic counselling, avoiding nephrotoxic agents, minimising CVS Risks Medical: Treatment of co-existing complications like HTN, infection Tolvaptan can slow cyst growth Dialysis Surgical: Nephrectomy alone, renal transplant +/- nephrectomy
64
What is the Bosniak system?
Classification system used classify the malignant risk of renal cysts based on CT findings
65
How would you complete your examination in suspected ADPKD patient?
History (FH) Obs (BP, temp) Urine (protein, haematuria, leukocytes) CVS examination for MVP/MR Neurological examination if concerns of Berry aneurysms DRE - Association with diverticular disease
66
When examining ADPKD, signs to look for/ important negatives
Evidence of CKD, CLD Current dialysis modes/ renal transplant Fluid status Evidence of uraemia Neurological deficits
67
What % of those > 60 with ADPKD have berry aneurysms
20% (5% in < 60)
68
What ix would you do if suspecting cerebral aneurysms?
MRA
69
Indications for nephrectomy in ADPKD
Pain Cyst rupture and haemorrhage Recurrent infection Space for tx Suspected malignancy
70
Von Hippel Lindau features
Spinocerebellar haemangioblastomas (ataxia) Bilateral renal cell carcinoma/ cysts Retinal haemangioblastoma Bilateral hydronephrosis
71
Tuberous sclerosis features
Ash-leaf macules Shagreen patches Adenoma sebaceum Ungal fibromas Retinal hamartomas Renal angiomyolipoma Renal cysts Epilepsy (80%) Learning difficulties/ autism Cardiac rhabdomyomas Lung lymphangiomyomatosis (LAM)
72
Renal angiomyolipoma Epilepsy
Tuberous sclerosis
73
Skin features in TS
Shagreen patches Subungual fibromas Adenoma sebaceum Ash-leaf macules
74
Alport syndrome features
Bilateral sensorineural deafness Non-visible haematuria Proteinuria CKD
75
Tolvaptan MOA
Vasopressin receptor 2 antagonist
76
Why do patients with tuberous sclerosis develop renal cystic disease?
TSC2 gene on chromosome 16 next to the PKD1 gene and as such they can develop manifestations of both diseases
77
Systems to examine if suspecting tuberous sclerosis
Skin + nails Kidneys: tremor, any RRT, transplant or nephrectomy scars, enlarged kidneys, CKD complications Lungs: lymphangiomyomatosis Heart: cardiac rhabdomyomas Eyes: fundoscopy Neurology
78
TS DDX
NF1 VHL
79
Best modality to look at ash leaf macules
Wood's lamp to view depigmented patches

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