Chronic Kidney Disease and Renal Failure

Question 1

What are the different functions of the kidney?

Answer 1

• homeostatic function
• excretory function
• endocrine function
• glucose metabolism

Question 2

What is the homeostatic function of the kidney?

Answer 2

• electrolyte imbalance
• acid-base imbalance
• volume homeostasis

Question 3

What is the endocrine function of the kidney?

Answer 3

• erythropoietin

- 1 alpha-hydroxylase vitamin D

Question 4

What is the excretory function of the kidney?

Answer 4

• nitrogenous waste
• hormones
• peptides
• middle sized molecules
• salt and water

Question 5

What is the glucose metabolism function of the kidney?

Answer 5

• gluconeogenesis

- insulin clearance

Question 6

What is the impact of the loss of the homeostatic function of the kidney?

Answer 6

• increased potassium
• reduced bicarbonate
• reduced pH
• increased phosphate
• salt and water imbalance

Question 7

What is the impact of the loss of the excretory function of the kidney?

Answer 7

• increased urea
• increased creatinine
• reduced insulin requirement

Question 8

What is the impact of the loss of the endocrine function of the kidney?

Answer 8

• reduced calcium
• anaemia
• increase parathyroid hormone levels

Question 9

What is the impact of the loss of the glucose metabolism function of the kidney?

Answer 9

increased cardiovascular risk

Question 10

What impacts the clinical presentation of kidney failure?

Answer 10

the rate of deterioration

Question 11

What causes the tachypnoea with normal oxygen and clear lungs on auscultation?

Answer 11

• hyperventilation

- metabolic acidosis

Question 12

What are the general symptoms of end stage renal failure?

Answer 12

• lethargy
• weakness
• anorexia
• hyperkalaemia
• hyponatraemia
• metabolic acidosis
• raised urea and creatinine

Question 13

What tends to be the impact of kidney failure on the salt water balance?

Answer 13

reduce secretion of salt and water, which can cause:

• hypertension
• oedema
• pulmonary oedema

Question 14

What is the impact of tubulointerstitial disorders on the salt water balance?

Answer 14

• damage to the concentrating mechanism
• hypovolemia
• AKI

Question 15

How can renal failure cause metabolic acidosis?

Answer 15

• reduced hydrogen secretion

- cells take up hydrogen ions, forcing out K+ ions

Question 16

What is the effect of this acidosis caused by renal failure?

Answer 16

• anorexia
• muscle catabolism
• weight and muscle mass loss

Question 17

What can cause hyperkalaemia?

Answer 17

• acidosis

- reduced distal tubule potassium secretion

Question 18

What are the symptoms of hyperkalaemia?

Answer 18

• cardiac arrhythmias
• neural and muscular activities
• vomiting

Question 19

What are the symptoms of hyperkalaemia dependent on?

Answer 19

chronicity

Question 20

What ECG changes can be caused by hyperkalaemia?

Answer 20

• peaked T waves
• P wave (broadened, reduced amplitude, or disappears)
• QRS widening
• heart block
• asystole
• VT/VF

Question 21

What is the impact of reduced erythropoietin?

Answer 21

anaemia

Question 22

What is the impact of reduced 1-25 vitamin D levels?

Answer 22

• reduced intestinal calcium absorption
• hypocalcaemia
• hyperparathyroidism

Question 23

What is the impact of phosphate reteintion?

Answer 23

• worsened hypocalcaemia

- leading to increased hyperparathyroidism

Question 24

What is the major predictor of end stage renal failure?

Answer 24

CKD

Question 25

What is the major outcome for a patient with CKD?

Answer 25

cardiovascular disease - arterial calcification - sudden cardiac death

Question 26

What is the cardiovascular risk factors with renal failure?

Answer 26

- hypertension - DM - lipid abnormalities - inflammation - oxidative stres - mineral/bone metabolism disorder

Question 27

What is the initial management of kidney failure?

Answer 27

hypovolaemic: IV fluids hypervolaemic: trial diuretics/dialysis

Question 28

How do you manage hyperkalaemia?

Answer 28

``` drive into cells - sodium bicarbonate - insulin dextrose (caution) drive out of body - diuretics/dialysis gut absorption - potassium binders ```

Question 29

What are the conservative treatments available for kidney failure?

Answer 29

- erythropoietin injections (anaemia) - diuretics (oedema) - phosphate binders - 1,25 Vit D supplements (symptom managment)

Question 30

What are the home treatments available for kidney failure?

Answer 30

- haemodialysis | - peritoneal dialysis/assisted programs

Question 31

What are the in-centre treatments available for kidney failure?

Answer 31

- haemodialysis (4hr x 3/week)

Question 32

What is the last line treatment for kidney failure?

Answer 32

transplantation

Question 33

How does hyperphostate present?

Answer 33

itchiness

Question 34

What should be avoided in transplantable patients with kidney disease?

Answer 34

- avoid transfusion, can lead to sensitisation and then increase risk of transplant failure - blood taken from the back of the hand (avoid the antecubital fossa), may be needed in future for dialysis

Question 35

Is urea an accurate indicator of kidney failure?

Answer 35

- poor indicator | - can be masked by diet, catabolic state, GI bleeding, drugs and liver function

Question 36

Is creatinine an accurate indicator of kidney failure?

Answer 36

- TREND is helpful | - affected by: muscle mass, age, race and sex

Question 37

Are radionuclide studies an accurate indicator of kidney failure?

Answer 37

- EDTA clearance... | - reliable but expensive

Question 38

Is creatinine clearance an accurate indicator of kidney failure?

Answer 38

- difficult for elderly patients to collect and accurate sample - overestimates GFR at low GFR (small amounts of creatinine is also secreted into urine)

Question 39

Is inulin clearance an accurate indicator of kidney failure?

Answer 39

- laborious | - used mainly for research purposes

Question 40

What indicators are used to indicate kidney failure?

Answer 40

eGFR (using CKD epidemiology collaboration)

Question 41

What impacts the efficacy of the CKD-EPI?

Answer 41

a high/normal eGFR

Question 42

What must be looked at when suspected kidney failure with normal eGFR/kidney function?

Answer 42

creatinine levels/trends

Question 43

If a patient is dehydrated, the filtrate present in which part of the nephron will have the highest osmolarity?

Answer 43

Tip of Loop of Henle

Question 44

What is likely to cause the highest osmolarity?

Answer 44

patient suffering with hepatic cirrhosis

Question 45

What solute has no effect on ADH production?

Answer 45

urea

Question 46

Why do most diuretics increase potassium excretion?

Answer 46

The increase in flow rate is detected in the collecting duct and directly stimulates potassium excretion

Question 47

An athlete after finishing their London Marathon run drank 2L of distilled water. How could you describe their body fluids?

Answer 47

decrease in plasma osmolarity

Question 48

Sodium excretion is very limited (less than 1% of filtered load) and several mechanisms exist to tightly regulate it. Increasing sodium excretion reduces water retention. Potassium excretion can vary over a very large range (from 1 to 80% of filtered load). Why doesn’t this variability in potassium excretion have a marked effect on water balance?

Answer 48

The amount of potassium in the plasma and extracellular is much lower than the amount sodium so that variations in this amount are insufficient to have a marked effect on water balance.

Question 49

Mr Holmes (65 years old, 75 Kg) is being treated with a loop diuretic and Mr Smith (66 years old, 74 Kg) with a thiazide diuretic for past 3 weeks (assume that the doses of the respective treatments allow an equivalent inhibition of [Na+] reabsorption). Both the individuals are drinking insufficient but equivalent amount of water. Which of the following statement is likely to be true?

Answer 49

Mr Holmes urine will have lower osmolarity than Mr Smiths.