Flashcards in Clinical (Week 5) Deck (188):
How quickly does blood flow through the dialysis machine?
The following ions are in the dialysate, but are they in higher or lower concentrations than the patients blood:
Na+ is lower
Bicarbonate is higher
K+ is lower
Glucose is about equal (if not slightly higher)
How is water removed from the patient?
Dialysate hydrostatic pressure
Why is pure water used for the dialysate?
No cytokines, bacteria or toxins present that may damage the patients
How efficient is dialysis?
If a patient was on dialysis 3hrs/3times/week, what would their absolute death risk increase be?
6% (1% for each half hour and they would be 3 hours down)
If a patient on dialysis is anuric, what must their fluid intake be restricted to?
1L per day
What foods contain high levels of K+ so should be avoided when a patient is on dialysis?
Why should a low phosphate diet be observed when on dialysis?
It isn't dialysed well
What should be avoided as they are high in phosphate?
When are phosphate binders taken and what do they do?
With meals (6-12 per day):
- Prevent GI phosphate absorption
What is the main con of using a Scribner shunt for dialysis?
When is a Scribner shunt still used?
For dialysis in AKI or ESRD
What veins can a tunnelled venous catheter be inserted into and which is preferred?
Which of the following can be used in dialysing and AKI patient:
- Scribner shunt
- Tunnelled venous catheter
Tunnelled venous catheter
In which of the following is infection most likely and with what organism:
- Scribner shunt
- Tunnelled venous catheter
Tunnelled venous catheter
If a dialysis site gets infected, what can result?
How is an infected dialysis line treated?
How does intradialytic hypotension arise?
ICF -> ECF -> Intravascular -> Hypotension
If a patient becomes fluid overloaded on dialysis, what can result?
Appearance of LVF
What drug should not be given if a patient on dialysis becomes fluid overloaded?
What are some other complications of dialysis?
Blood leaks -> Exsanguination?
Loss of vascular access
Hypokalaemia -> Cardiac arrest
What drives water removal across the peritoneal membrane in peritoneal dialysis?
High [Glucose] in the dialysate fluid
How is continuous peritoneal dialysis carried out?
4 bag exchanges per day
Fluid drained then replaced
30 minutes per exchange
How is automated peritoneal dialysis carried out?
1 bag left in all day
Overnight machine drains it in and out (over 9hrs)
What are the benefits of continuous peritoneal dialysis?
Where can infection arise in peritoneal dialysis?
What are typical contaminants that cause infection in peritoneal dialysis patients?
What gut bacteria can cause infection in peritoneal dialysis patients?
What must we do before treating infection in peritoneal dialysis?
Culture PD fluid
What is the treatment for peritoneal dialysis infections?
- Vancomycin + Gentamicin
In what peritoneal dialysis infections must the catheter be removed?
Why can peritoneal dialysis only last so long?
Peritoneal membrane thickens -> Inability to remove enough fluid
What can an increased intra-abdominal pressure on standing cause in peritoneal dialysis?
What symptoms may indicate the need for dialysis?
How long does the 1st session of haemodialysis usually last?
Why is the 1st session of haemodialysis shorter?
Prevent disequilibrium syndrome:
- Cerebral oedema
Which of the following might indicate the need for withdrawal from dialysis:
- Cerebrovascular disease
- Liver failure
- Increased patient fragility
- Palliative care
How is overt diabetic nephropathy defined?
-> On >2 occasions
-> 3-6 months apart
How does autonomic neuropathy present in diabetes?
What haemodynamic changes are involved in diabetic nephropathy?
1. Afferent arteriolar vasodilation:
- Mediated by vasoactive chemicals (IGF-1)
3. Increased GFR
What causes renal hypertrophy in diabetic nephropathy?
Increased plasma glucose -> Renal growth factors
What is a Kimmelstiel-Wilson Lesion?
Nodular diabetic glomerulosclerosis
What does proteinuria indicate in diabetic nephropathy?
How can we try and prevent diabetic nephropathy?
What is the most common causes of renovascular hypertension?
Renal artery stenosis
What causes ischaemic nephropathy?
Reduced GFR associated with renal hypoperfusion beyond level of autoregulatory compensation
What can ischaemic nephropathy result in?
What is the prevalence of fibromuscular dysplasia?
What people are most commonly affected by fibromuscular dysplasia?
Females aged 15-50yrs
What percentage of fibromuscular dysplasia cases are familial and how do they tend to present?
Involving both renal arteries
What is fibromuscular dysplasia associated with?
If fibromuscular dysplasia involves the cerebral arteries, what can happen?
Carotid artery dissection
What patients does atherosclerotic renovascular disease tend to affect?
Caucasian males aged >50yrs
With what do patients with renovascular disease tend to present?
AKI after ACEi treatment
How can patients with atherosclerotic renovascular disease present?
Flash pulmonary oedema
Which of the following is not useful in screening for ischaemic renal disease?
- Renal USS
- Renal artery duplex studies
- Urine microscopy
- CT/MRI angiography
How are the majority of ischaemic renal disease patients treated?
What surgical options are useful in treating ischaemic renal disease?
Angioplasty (+/- stenting)
When are ACEi inhibtiors contra-indicated in renovascular disease?
Bilateral renal artery stenosis
What is myeloma?
Cancer of plasma cells
How does myeloma cause disease?
Abnormal plasma cells accumulate in bone marrow:
- Interfere with normal RBC production
What antibody can also be produced by myelomas?
Which of the following is not a sign of myeloma:
- Recurrent infections
- Renal failure
Which of the following is not a symptom of myeloma:
- Bone pain
- Weight loss
On blood tests, what are the signs of myeloma?
Normocytic anaemia (in 75%)
Rouleaux formation (chains of RBCs) (in 50%)
Increased CRP/PV (in 30%)
Apart from blood testing, what other investigations can be carried out for myeloma?
BJP in urine
Lytic lesions on skeletal survey
What are the peak ages of myeloma incidence in males and females?
Males - 80 years
Females - 70 years
In what populations is the risk of myeloma doubled?
What percentage of myeloma patients have renal impairment at presentation?
What percentage of myeloma patients need dialysis at presentation?
Which of the following is not a renal manifestation of myeloma:
- AKI (secondary to hypercalcaemia)
- Monoclonal Ig Deposition disease
- Cast nephropathy
What is the pathology of amyloidosis?
Deposition of proteinaceous material in extracellular spaces
How is amyloidosis classified?
By type of precursor protein that makes up the main component of the fibrils
What are the two classes of renal amyloidoses?
Primary amyloid (Amyloid Light-chain [AL])
Secondary amyloid (Serum Amyloid A [AA])
What is the classical histological appearance of amyloidosis?
Positive Congo-Red staining:
- Showing apple-green birefringence
-> Under polarised light
What nephrotoxins need stopped in myeloma with acute renal failure?
Diuretics (increase risk of cast formation)
How do we treat hypercalcaemic in myeloma?
IV saline for volume resuscitation
What can reduce the tumour load in myeloma?
High dose dexamethasone
What can plasma exchange do in the treatment of myeloma?
Removes amyloid light chains
What is GPA?
Necrotising granulomatosis inflammation
Where does GPA most commonly affect?
How does EGPA usually present?
Asthma (>95%) and eosinophilia
What percentage of EGPA patients have skin involvement and what skin features would be present?
Is microscopic polyangiitis necrotising?
Why can microscopic polyangiitis result in pulmonary haemorrhage?
Alveolar capillary involvement
In what two small vessel vasculitides is renal involvement more common?
How does small vessel vasculitis-related renal disease present?
How do small vessel vasculitides appear on renal biopsy?
Segmental necrotising GN (crescent)
What percentage of SLE patients have renal involvement at presentation?
What percentage of SLE patients will have some renal involvement during the course of their disease?
What is the most common presentation of lupus nephritis?
In the ISN classification of lupus nephritis, what do each of the Classes I-VI mean?
Class I -> Minimal mesangial
Class II -> Mesangial proliferative
Class III -> Focal proliferative
Class IV -> Diffuse proliferative
Class V -> Membranous
Class VI -> Advanced sclerosing
What antihypertensive treatment is used in lupus nephritis and what is the target BP?
How do we induce immunosuppression in lupus nephritis?
High dose steroids
Azathioprine, Rituximab + Tacrolimus
How do we maintain immunosuppression in lupus nephritis?
Which of the following is not a poor prognostic factor in systemic disease:
- Renal disease
- Poor socio-economic status
- Antiphospholipid syndrome
- High disease activity
Female (Being male is a poor prognostic factor)
What drugs can cause intrarenal failure?
What drugs can cause post-renal failure?
Which type of adverse drug reaction has a high mortality?
Type B (Bizarre reactions)
What are some examples of Type B adverse drug reactions?
Bone marrow aplasia due to Chloramphenicol
Hepatic necrosis due to Halothane
Give examples of Type C adverse drug reactions (chronic)?
Steroids -> Cushing's
β-Blockers -> Diabetes
NSAIDs -> Hypertension
What types of affects are usually seen in Type D adverse drug reactions?
What are some examples of Type D adverse drug reactions?
Secondary malignancies post-chemotherapy
Craniofacial abnormalities in kids of women taken isotretinoin
What can β-blocker therapy withdrawal result in?
What can steroid therapy withdrawal result in?
What drugs does theophylline commonly interact with?
Macrolide antibiotics (Clarithromicin, Eryhtromicin)
What drugs do statins commonly interact with?
Macrolides and Fibrates
What drugs do ACEi commonly interact with?
What drugs does clopidogrel commonly interact with?
What drugs can exacerbate CHF?
What drugs can cause urinary retention in BPH?
What drugs can worsen constipation?
Calcium channel blockers
Potassium rich foods (bananas, oranges and green leafy vegetables) interact with what drugs?
K+ sparing diuretics
Vitamine E and K rich foods (apples, chickpeas, spinach, nuts, kiwi and broccoli) interact with what drug?
Foods that alter pH (chicken, turkey, milk, soy, cheese, yoghurt) interact with what drugs?
Which foods interact with cytochome P450 and what drugs can this affect?
Grapefruit, apple, orange and cranberry:
What is the first stage of drug development and what are features of this stage?
- Most efficient
- Least attrition (Financial cost, morbidity/mortality)
What phases of drug development are clinical tries and what are some features of these stages?
Limited sample size:
- Low frequency adverse drug reactions
- Time lag ADR
Exclusion of frail patients
What are some features of post-marketing surveillance?
- Financial cost, morbidity/mortality
Most data available
What is LD50?
The amount of ingested substance/drug that kills 50% of a test sample
What is ED50?
The effective dose for 50% of people receiving the drug
How is the therapeutic index calculated?
What is Phase 1 of drug metabolism?
Usually through cytochrome P450:
- Oxidation, Reduction and Hydrolysis
What is Phase 2 of drug metabolism? What does it allow?
Conjugation -> Water soluble
Enables excretion in urine or bile
During what phase of drug metabolism do most adverse drug reaction occur?
What two mutations can result in ADPKD and what chromosomes do they appear on?
PKD1 gene mutations (85% of cases):
- Chromosome 16
PKD2 gene mutations:
- Chromosome 4
Which mutation causing ADPKD results in earlier ESKD?
PKD1 gene mutations
What is the pathology of ADPKD?
Epithelial-lined cysts arise from a small number of tubules
Benign adenomas (25% of kidneys)
What is the mean age for hypertension in ADPKD?
What can cause haematuria in ADPKD?
Is ADPKD painful?
Yes it can be
What is the most common extra-renal manifestation of ADPKD and when do they appear?
Hepatic cysts ten years after renal cysts
What can hepatic cysts in ADPKD cause?
True or false; Hepatic cysts in ADPKD often allow the liver to continue function?
What percentage of ADPKD patients can suffer from intracranial aneurysms?
Where do ADPKD-related intracranial aneurysms tend to arise?
Anterior circulation territory
When would you screen for ADPKD-related intracranial aneurysms?
What cardiac disease can result due to ADPKD?
Mitral/Aortic valve prolapse
- Collagenous/Myxomatous degeneration
What can profoundly increase the risk of diverticular disease in ADPKD?
If they are on dialysis
By what percentage is the incidence of abdominal and inguinal hernias increased in ADPKD?
What renal changes can be seen on USS of ADPKD?
Multiple, bilateral cysts
What genetic investigations can be done into ADPKD?
Early onset ADPKD presents in what patients?
Kids in their 1st year of life
How can early onset ADPDK be distinguished from ARPKD?
- ARPKD shows congenital hepatic fibrosis
How is ADPKD diagnosed in children?
One cysts on USS in a high risk patient
How common are cerebral aneurysms in early onset ADPDK?
What is the main treatment for ADPKD?
Rigorous hypertension control
What does Tolvaptan do?
Reduces cyst volume and progression
If a patient with ADPKD is in renal failure, what treatments can be offered?
Cardiovascular and Cerebrovascular disease prevention
Who does ARPKD present in?
How common are hepatic lesions in ARPKD?
What is the incidence of ARPKD?
What is the genetic linkage in ARPKD?
PKDH1 (On chromosome 6)
Where do the cysts arise from in ARPKD?
Which of the following is not a common presenting sign in ARPKD:
- Kidneys always palpable
- Recurrent UTI
- Chronic pain
- Slow decline in GFR
What percentage of ARPKD patients die in the 1st year of life?
If a patient with ARPKD survives the 1st year of life, what is the chance the patient will survive >15 years?
What is Alport's syndrome?
Hereditary nephritis due to a disorder of Type IV collagen matrix
What percentage of patients with ESKD have Alport's syndrome?
What is the most common inheritance of Alport's syndrome?
What is the common gene mutation in Alport's syndrome and what does it cause?
- Deficient collagenous matrix
What is the characteristic feature of Alport's syndrome?
When does proteinuria occur in Alport's syndrome and what is it a sign of?
Bad prognostic indicator
What are some extra-renal manifestations of Alport's syndrome?
- Anterior lenticonus -> Conical protrusion of lens
- Keratoconus -> Conical corneal protrusion
Leiomyomatosis of oesophagus/genitals (rare)
When should Alport's syndrome be suspected?
Haematuria +/- Hearing loss
How does Alport's syndrome appear on renal biopsy?
Variable thickness GBM (characteristic)
Lamina densa splitting
How is Alport's syndrome treated?
Aggressive treatment of:
What is Anderson Fabrys Disease?
Inborn error of glycosphingolipid metabolism:
- α-galactosidase A deficiency
- Lysosomal storage disease
What type of inheritance is Anderson Fabrys Disease?
Which of the following does Anderson Fabrys Disease not affect:
How will a renal biopsy appear in Anderson Fabrys Disease?
Concentric lamellar inclusions within lysosomes
What is the main cutaneous feature of Anderson Fabrys Disease?
What are some cardiovascular features of Anderson Fabrys Disease?
What are some neurological features of Anderson Fabrys Disease?
How can Anderson Fabrys Disease be diagnosed?
Plasma leukocyte α-GAL activity
What is an angiokeratoma?
A benign cutaneous lesion of capillaries, resulting in small marks of red to blue color; characterized by hyperkeratosis
How is Anderson Fabrys Disease treated?
What pattern of inheritance does Medullary Cystic Kidney show?
What is the pathology behind Medullary Cystic Kidney?
Abnormal renal tubules -> Fibrosis
Cysts in the corticomedullary junction and medulla
What size are kidneys in Medullary Cystic Kidney?
How is Medullary Cystic Kidney diagnosed?
When does Medullary Cystic Kidney present?
~28 yers of age
What is the best treatment for Medullary Cystic Kidney?
What sort of inheritance does medullary sponge kidney show?
What is the pathology behind medullary sponge kidney?
Dilatation of collecting ducts
What do the cysts have in medullary sponge kidney?