CKD and ESKD Flashcards
1
Q
What is the primary process by which solutes will be removed by PD?
A
Diffusion and convection
2
Q
What is the recommended minimum weekly Kt/V in PD?
A
Kt/V of 1.7 (it is the minimum, not the target!)
3
Q
What are the benefits of frequent hemodialysis? (hint: 4)
A
- less LVH
- better HTN control
- better control of hyperphosphatemia
- better volume control
4
Q
What are the risks of frequent hemodialysis? (hint: 5)
A
- vascular access trauma
- less residual kidney function
- increased burden on the patient and caregiver
- more expense
- more intradialytic hypotension
5
Q
True or False
Renal and Peritoneal clearance equally contribute when calculating Kt/V in PD
A
TRUE
6
Q
What are the long term complications of uremia (hint: 4)
A
- dialysis acquired amyloidosis
- accelerated CV risk
- uremic platelet dysfunction
- Immunodeficiency
7
Q
How can you improve ultrafiltration in PD?
A
increasing dextrose concentration
8
Q
What are ways to improve PD clearance? (hint: 3)
A
- increase the fill volume
- increase the # of exchanges
- optimize the dwell time
9
Q
what is the only diuretic other than spironolactone that can be used by a patient with sulfa allergy?
A
ethacrynic acid
10
Q
What is the minimum sp KT/V recommended in patients doing 3x/weekly intermittent HD?
A
sp Kt/V of 1.2, but better if the sp Kt/V is 1.4
11
Q
what is the cause of the cough a/w ACEI?
A
Bradykinin. the inhibition of ACE causes bradykinin to accumulate in the airways
12
Q
which ACE inhibitor is poorly dialyzed
A
Fosinopril
13
Q
Which class of drugs are dialyzable? ACEi or ARBs?
A
ACEI are dialyzable, ARBs are not.
14
Q
why are ARBs preferred over ACEi in the CKD population?
A
ARBs have shown to produce a greater decrease in CVE than ACEi, especially among patients with established CVD. (LIRICO trial)
15
Q
to avoid clotting in postdilution CVVH, what threshold should you keep the filtration fraction under?
A
under 25%
16
Q
during CRRTm what risk develops when the ratio of total calcium to iCa is > 2.5?
A
citrate toxicity
17
Q
what is the treatment for BZD overdose?
A
Flumazenil (a BZD antagonist)
18
Q
which toxic alcohol is found in rubbing alcohol?
A
isopropyl alcohol. It’s also found in hand sanitizer.
Windshield washer contains methanol
Deicing fluid/antifreeze contains athylene glycol
19
Q
name 2 glomerular syndromes that can be present in liver disease.
A
IgAN; cryoglobulinemia; MPGN
20
Q
what is expected to be present in the urine of a patient who ingested ethylene glycol?
A
calcium oxalate crystals
21
Q
what is a risk a/w rasburicase?
A
- G6PD deficiency (always check for GP6PD levels prior to starting it)
- methemoglobinemia
- anaphylaxis
- Abs develop in 10-20%
22
Q
True or False. There is benefit in starting RRT earlier rather than later in ICU patients
A
False. There is no conclusive benefit (STARRT AKI, AKIKI 1)
23
Q
Which form of CRRT anticoagulation has the greatest success in preventing circuit clotting?
A
citrate
24
Q
what is the renal injury that causes AKI with use of the drug ecstasy?
A
Rhabdomyolysis. Hyponatremia is also common
25
name a drug that will lower creatinine clearance but not true GFR. (Bonus: name 4)
trimethoprim (Bactrim) and cimetidine, cobicistat, dolutegravir. They inhibit tubular secretion of creatinine via OCT2
26
name 3 risk factors for dialysis disequilibrium syndrome (bonus: 7)
1. first treatment 2. young/old 3. very high BUN 4. hypernatremia 5. hyperglycemia 6. metabolic acidosis 7. preexisting neurologic abnormalities
27
predilution CVVH will (increase/decrease) clearance, (increase/decrease) clotting?
decrease clearance, decrease clotting
28
what is caused by excessive chloramines in the dialysate during iHD?
Hemolysis
29
what is the base source of HCO3 in PD dialysate?
1. acetate
2. citrate
3. lactate
Lactate
30
name 2 situations that may necessitate urine alkalinization?
1. uric acid stones
2. methotrexate overdose
3. salicylate overdose
31
which CRRT modality has the highest clearance assuming the effluent rate is the same?
1.CVVH predilution
2. CVVH postdilution
#. CCHDF predilution
CVVH post dilution. predilution lessens clotting but will decrease clearance because some of the effluent is replacement fluid.
32
name 3 potential electrolyte complications when using citrate in CRRT?
hypocalcemia, metabolic alkalosis (citrate in excess), metabolic acidosis (citrate toxicity), hypercalcemia (excess calcium drip), hypernatremia (trisodium citrate formulation)
33
what is the pressure threshold that defines abdominal compartment syndrome?
> 20 mmHg; >12 mmHg defines intraabdominal hypertension
34
name a histological findings of ATN
1. loss of the PT brush border
2. granular casts in tubules
3. tubular cell mitoses
35
what is the treatment for acyclovir-associated AKI?
hemodialysis
36
AKI in myelomonocytic leukemia is related to the overproduction and excretion of what LMWP?
lysozyme
37
which drug is a/w G6PD related hemolysis?
1. rasburicase
2. rituximab
3. INH
4. quinine
rasburicase
38
name 2 causes of hemoglobinuric AKI
1. transfusion reaction
2. P. falciparum malariae
3. mechanical heart valve
4. PNH
5. trauma from exercise/ prolonged standing
6. hantavirus
39
name the renal pathologic finding in snake bite related AKI which is common in Asia.
TMA or cortical necrosis
40
match the bisphosphonate with the renal lesion
1. pamidronate 2. zolendronate
A. collapsing FSGS, B. ATN
pamidronate - collapsing FSGS
zolendronate - ATN
41
match the ff
1. cisplatin 2. Mitomycin C & gemcitabine 3. VEGFi
a. HUS/TMA. b. hypoMg
1B, 2A 3A
42
whcih common additive to cocaine can cause ANCA associated vasculitis?
levamisole
43
true or false
iHD can prevent contrast associated nephropathy
False
44
which contrast medium has the lowest osmolality, iso-osmolar or low-osmolar?
iso-osmolar
Low-osmolar contrast is still high at 320-800 mOsm/L, vs iso-osmolar contrast which is 290 mOsm/L
45
what is the purpose of the furosemide stress test?
to prognosticate among those with AKI II or III if they will end up needing dialysis. In AKI, an increase in UOP after lasix indicates an improved prognosis
46
name a cause of osmotic nephrosis
1. IVIG if with sucrose formulation
2. mannitol
3. SGLT2 inhibitors
47
an elderly patient develops AKI after a routine colonoscopy. what may be present on renal biopsy?
CaPO4 deposition in renal tubules. this scenario is less common since the d/c of oral phosphate-based bowel prep.
48
what is the easiest wat to diagnose pseudo AKI from a urine leak into the abdomen?
send urine ascites for creatinine analysis; the result will be greater than the serum creatinine value
49
what antibiotic increases the risk of AKI when given with vancomycin?
Pip-tazo
50
name a balanced IVF
LR and plasmalyte
51
what kind of urine pH is MTX most likely to cause crystals?
acidic urine
52
name one situation where CRRT would be better than iHD?
high intracranial pressure
53
Mnemonic for CYP450 inducers
CRAPS out drugs
Carbamazepine, rifampicin, bArbiturates, Phenytoin, St. John's wort
54
match the hyperK treatement with the AE:
1. Patiromer, 2. Lokelma
a. hypoMg, b. edema
patiromer: hypomG
lokelma: edema
55
how does heparin cause hyperK?
heparin (-) aldosterone release. therefore less K secretion in the CD
56
in hypokalemic periodic paralysis, which characteristic fits best?
1. asian male & hyperthyroidism
2. asian female & hyperthyroidism
3. licorice ingestion
Asian male and hyperthyroidism
57
fill in the blank with 3 electrolytes
Refeeding results in low ___
Low phosphate, potassium, magnesium
58
Name the acid or metabolic acidosis associated with each of these:
1. acetaminophen
2. linezolid
3. SGLT2 inhibitor
acetaminophen = HAGMA (cause of oxoproline)
Linezolid = HAGMA, lactic acidosis
SGLT2i = beta hydroxybutyrate
59
ingestion of isopropyl alcohol results in which of the ff?
1. NAGMA
2. Ketoacidosis
3. ketosis without acidosis
Ketosis without acidosis
Isopropyl alcohol gets metabolized to acetone. Ketones are very weak acids and do not cause acidosis
60
how does omperazole (PPIs) result in hypomagnesemia?
PPIs decreases GI absorption og Mg by inhibiting TRPM6 chain. Renal Mg can. below.
61
what is the flow of a high output AVF?
flow > 1500 ml/min
62
VEGF inhibitors (e.g. bevacizumab) and axitinib (TKI) are metabolized by CYP450, so what antihypertensives should be avoided?
non-DHP CCBs (e.g. verapamil, diltiazem) nifedipine because they inhibit CYP450; nifedipine because they cause VEGF expression
63
what is the most likely diagnosis in a patient with ESKD presents with hip pain, xray shows a lytic lesion on the pelvis, PTH is 1500 pg/mL, Ca 8.4, PTH 4.8?
osteitis fibrosa cystica (aka brown tumor)
64
Match
1. Cat contamination
2. Bird contamination
3. Sheep or cows
A. Brucella spp
B. Fungal
C. Pasteurella spp
1, C
2, B
3, A
65
Treatment for eosinophilic peritonitis (aka peritoneal eosinophilic serositis)
Oral antihistamines
Systemic steroids, if persistent
66
What is High venous pressure in the CRRT?
Pressure > 250 mmHg
67
Causes of high venous pressure in CRRT
Kinks, thrombus in the catheter, central vein stenosis, clotting in the dialyzer
68
What is the best way to prevent access thrombosis?
Aspirin and dipyrimadole
69
What is the minimum diameter for veins to predict AVF maturation?
Minimum of 2.5 mm
70
Name 2 ACEi that are dialyzable & 2 that are non-dialyzable
Dialyzable: lisinopril, captopril
Non-dialyzable: benazepril, fosinopril
71
are CCBs dialyzable or non-dialyzable?
Non-dialyzable
72
Which CNI causes hirsutism and gingival hyperplasia?
Cyclosporine
73
Which CNI causes hair loss and post-transplant diabetes?
Tacrolimus
74
What are the major side effects of AZT? (Hint: 3)
bone marrow suppression, veno-occlusive disease, pancreatitis
75
What are the major side effects if
mTOR inhibitors?
BM suppression, delayed wound healing, hyperlipidemia, lymphedema, proteinuria (FSGS)
76
What is the PO to IV conversion of CsA and TAC?
IV is 1/3 the oral dose
77
What is the PO to SL dose conversion if TAC?
SL dose is 1/2 the PO dose
78
At what level of CrCl should edoxaban NOT be used?
Edoxaban should NOT be used if CrCl is > 95 ml/min. In the ENGAGE AF-TIMI trial, patients with a CrCl of > 95 had an increased rate of ischemic stroke vs warfarin
79
What life threatening side effects can occur if you combine clonidine + beta blockers?
Severe bradycardia, asystole
80
Poison case.
What drugs can be removed by dialysis?
1. Salicylate
2. Lithium
3. Alcohols - methanol, ethylene glycol, isopropyl alcohol
4. Theophylline
5. Valproate
6. Methotrexate
7. Phenobarbital
8. Metformin
81
What is the treatment of choice for acetaminophen poisoning?
N-acetylcysteine
- it will prevent or alleviate the hepatotoxicity by restoring hepatic glutathione stores
82
What is the indication for HD in the case of alcohol poisoning?
Do iHD if the alcohol level is > 50 mg/dL, severe metabolic acidosis or end-organ damage
Use large surface area dialyzers (>1.5 m2) along with high Qb > 300 ml/min
83
At what GFR is metformin contraindicated?
Stop or do not give metformin if GFR < 30
84
Hemodialysis is indicated in metformin lactic acidosis if the ff is present:
1. Lactate level > 20
2. Severe metabolic acidosis pH < 7.0
3. Medical treatment failure - no response to sodium bicarbonate
85
Glutamine, the substrate for NH3, is taken up by the proximal tubular cells via _____
SNAT3 (sodium dependent amino acid transporters)
86
what syndrome has presents with goiter, sensorineural deafness, and metabolic alkalosis
pendred syndrome
87
What is the defect or mutation in Pendred syndrome?
Defective pendrin or the Cl/HCO3 exchanger in the beta intercalated cells of the CD
88
What is the appearance of blood in the venous line during HD when there is chloramine contamination?
"portwine" appearance
89
s/sx of lead nephropathy
classic triad: HTN, gout, CKD,
others: cognitive impairment, peripheral neuropathy, microcytic anemia, proximal tubulopathy
90
occupational hazard for lead nephropathy
esp. battery workers,
others: smelting, paint removal, fuel, paint, and ammunition production
91
alcoholic drink that can be a risk factor for lead nephropathy
moonshine
92
what are risk factors for calciphylaxis?
warfarin, diabetes, insulin > 3x/d
93
what is the treatment for calciphylaxis that is given during iHD
sodium thiosulfate
dose is 12.5 g per iHD if wt < 60kg
dose is 25 g per iHD if wt > 60kg
94
what is the size cutoff for tumor excision in patients with renal cysts related to vHL?
tumors >/= 3 cm may be excised; < 3 cm observe
95
at what age do we start screening for renal manifestations in vHL?
screen by age 10
96
definition of UF failure in PD?
inability to achieve > 750 mL of UF in an anuric PD patient
97
what is the rule of 4 in PD UF failure?
UF of < 400 mL after a 4 hour dwell of 2 L of 4.25% dextrose
98
in the water treatment system, what is the role of a water softener?
it removes positively charged ions (e.g. Ca, Mg, Heavy metals) from the water to prolong the life of the RO system
99
in the water treatment system, what removes the positively charged ions?
water softener
100
in the water treatment system, what is the role of the carbon tanks?
it removes chlorine and chloramine or other organic solvents
101
how often should the carbon tanks be tested?
before every shift or every 4 hours
102
exhaustion or malfunction of the carbon tanks will result in?
Hemolysis
103
in the water treatment system, what is the role of RO?
it removes metal ions, aqueous salts, bacterai and viruses based on charge and MW
104
what is the role of a deionizer in the water treatment system?
it exchanges H+ and anions for OH- to form H2O
105
exhaustion or dysfunction of the deionizer will result in?
Fluoride or copper accumulation
106
in the water treatment system, what is required if deionization or UV light is used?
micron ultrafilter - removes bacteria and exotoxins
107
how do you calculate for extraction ratio of BUN during dialysis?
[preBUN - postBUN]/preBUN x 100
108
what is the formula for dialysis clearance (Kd) of BUN after hemodialysis?
Dialysis clearance = Extraction ratio x Blood flow
since Extraction ratio is never >1, therefore Clearance will never exceed blood flow
109
How to assess if a patient is getting adequate clearance while on intermittent hemodialysis?
measure weekly Kt/V (std Kt/V)
K is the Kd of urea
Kd urea = [(pre BUN - post BUN)/preBUN] x Qb
T is time on dialysis
V is the Vd of urea = TBW x 0.5
110
what is the capillary blood flow rate in the peritoneum?
50-100 ml/min
111
Majority of the pores in the peritoneum are ultrapores, small pores or large pores?
Small pores (95%)
Ultrapores compres 3%, large pores comprise 2%
112
TRUE or FALSE.
The PET test is used to determine overall survival, PD success or outcome.
FALSE
113
the PET test is done to assess what?
to assess peritoneal membrane characteristics which can help dictate the PD prescription
114
what is the management for patients with a stenosis at the fistual anastomosis or draining vein?
angioplasty or surgical revision
115
what is the management for a fistula with a large accessory vein?
surgical ligation
116
what is the management for a deep fistula?
superficialization
117
what is the depth (mm) of a deep fistula
found > 5mm away from the skin surface
118
what is the incidence of AVF non-maturation?
20-60% ( was 60% in the DAC study)
119
what are associated risk factors for fistula non-maturation?
female, elderly, PAD, forearm, h/o PICC lines or CVC, IVDU,
120
Preoperative mapping of arm veins will decrese the rate of non-maturation of AVF
True or false?
False.
it only allows for more patients to get an AVF, but the rate of non-maturation persists
121
what arterial diameter is considered ideal for AVF creation?
2.0 mm and above
122
what venous diameter is ideal for AVF creation?
2.5 mm and above
123
AVF matures usually at how many weeks post-op?
6 weeks
124
what is the US criteria for ADPKD diagnosis in a PKD1 family or if +FHx for ESRD < 55 in a patient who is < 30 years old?
at least 2 cysts in either or both kidneys
125
what is the US criteria for ADPKD diagnosis in a PKD1 family or if +FHx for ESRD < 55 in a patient who is 30-59 years old?
at least 2 cysts per kidney
126
what is the US criteria for ADPKD diagnosis in a PKD1 family or if +FHx for ESRD < 55 in a patient who is > 60 years old?
at least 4 cysts per kidney
127
what is the US criteria for ADPKD in family of unknown genotype in a patient who is 15-39 years old?
at least 3 cysts in either or both kidneys
128
what is the US criteria for ADPKD in family of unknown genotype in a patient who is 40-59 years old?
at least 2 cysts per kidney
129
what is the US criteria for ADPKD in family of unknown genotype in a patient who is >60 years old?
at least 4 cysts per kidney
130
What is the US criteria to rule out ADPKD?
age 40 and above with < 2 cysts total
131
what has a worse prognosis? truncating or non-truncating PKD1 mutation?
truncating PKD1 mutation
132
what has a better prognosis, PKD1 or PKD2 mutation?
PKD2 mutation
- later onset, smaller TKV, less cysts, later onset of ESKD
133
what is the mutation in ADPKD?
PKD1 and PKD2
134
what are other mutations with ADPKD like phenotype? (2)
GANAB and DNAJB11
135
A patient with bilateral kidney cysts, preserved kidney function, and mild to severe polycystic liver disease is a/w ____?
GANAB or DNAJB11?
GANAB
136
A patient with normal sized kidney but with multiple cysts, slow evolution to ESKD and absent-moderate polycystic liver disease is a/w?
GANAB or DNAJB11?
DNAJB11
137
what is the indication for tolvaptan use in a patient with ADPKD?
those with Mayo Class 1C, 1D, 1E witj rapidly progressive ADPKD, eGFR > 25 ml/min
138
tolvaptan is contraindicated in what situation?
liver failure or elevated liver enzymes
139
how will you monitor liver function test in a patient on tolvaptan?
measure LFTS at baseline, then 2 weeks, 4 weeks and every month for 18 month, then every 3 months thereafter
140
what is the target urine osmolality in ADPKD>?
urine osm < 280
141
according to the HALT PKD study, what is the target BP in ADPKD patients with eGFR > 60 vs eGFR < 60?
eGFR 60: intensive BP control < 110/75
eGFR < 60: BP goal < 130/80
intensive BP control is a/w 14.2% slower rate of TKV growth over 5 years
142
What is the preferred order of the class of antiHTN meds in PKD?
ACEi or ARBS > beta blocker > alpha blocker > DHP CCB > Diuretics
143
What percentage most closely reflects the prevalence of biopsy proven AIN in patients witH AKI?
10-15%
144
What is the goal Hba1C for patients who are diabetic but are pregnant?
Goal HbA1C is < 6.5%
(Strict metabolic control)
30% increased risk for fetal malformations for every increase of 1% in HbA1c
145
What is the risk of CKD progression in patients with known FSGS who becomes pregnant if the serum crea is > 2.4, proteinuria is > 3g/d?
> 50% risk of CKD progression during pregnancy or within 6 months post-partum
146
Using sucralfate will increase the risk for what type of toxicity?
Aluminum toxicity
147
What are the signs and symptoms of aluminum toxicity?
neurologic symptoms, bone pain, fractures, hypercalcemia, EPO hyporesponsiveness, dementia
148
Sodium azide exposure can cause ____?
A. Seizures
B. Hypotension
C. Hemolysis
Hypotension
149
Dialysis water exposed to agricultural run-off or well-water can increase the risk for ___ toxicity?
A. Nitrate toxicity
B. Lead Toxicity
C. Copper Toxicity
Nitrate toxicity
150
Methhemoglobinemia can be caused by ___ toxicity and exposure to what type of cleaning agent?
Nitrate toxicity & hydrogen peroxide
151
What are the signs and symptoms of hydrogen peroxide exposure?
methemoglobinemia, nausea, abd pain, back pain, hemolysis
152
what is the treatment for methemoglobinemia?
methylene blue
153
What is the safe fluoride cut-off?
Fluoride < 0.2 PPM
154
what level of fluoride is associated with death?
Fluoride levels > 15 PPM
155
What is the definition of immunity to Hepatitis B?
HbsAb titers of > 10 IU/L
156
How often should HbsAg be tested for ESKD patients who are immune to HBV?
annual testing
157
How often should HbsAg be tested for ESKD patients who are not immune to HBV?
monthly testing
158
What are concerning features for renal cell carcinoma if you see cysts in an ESKD patient?
size > 3 cm or septations
159
What study will you request if a patient has a 3cm renal cyst with septations on US?
get a CT scan or MRI to evaluate for renal cell carcinoma
160
What level of serum potassium is associated with high mortality rates among ESKD patients?
serum potassium > 5.7 mEq/L
161
what level of pre-dialysos serum potassium is associated with the lowest mortality?
serum K of 4.6-5.3 mEq/L
162
What is the estimated length of survival (days) if an ESKD patient decides to stop dialysis?
7-10 days
163
what are the values of D/P creatinine and D/P glucose of high or fast transporters?
D/P creatinine > 0.6 to 0.8
D/P glucose is < 0.4
164
what are the values of D/P Creatinine and D/P Glucose of low or slow transporters?
D/P creatinine is < 0.5 to 0.6 and D/P glucose is > 0.4
165
what are the benefits of icodextrin? (4)
1. better UF = better BP control
2. Better phosphate control
3. better lipid profile
4. longer technique survival
