Clinical (Week 5) Flashcards
(188 cards)
1
Q
How quickly does blood flow through the dialysis machine?
A
300ml/min
2
Q
The following ions are in the dialysate, but are they in higher or lower concentrations than the patients blood:
- Na+
- Bicarbonate
- K+
- Glucose
A
Na+ is lower
Bicarbonate is higher
K+ is lower
Glucose is about equal (if not slightly higher)
3
Q
How is water removed from the patient?
A
Dialysate hydrostatic pressure
4
Q
Why is pure water used for the dialysate?
A
No cytokines, bacteria or toxins present that may damage the patients
5
Q
How efficient is dialysis?
A
Not very:
- 10-12ml/min/1.73m^2
6
Q
If a patient was on dialysis 3hrs/3times/week, what would their absolute death risk increase be?
A
6% (1% for each half hour and they would be 3 hours down)
7
Q
If a patient on dialysis is anuric, what must their fluid intake be restricted to?
A
1L per day
8
Q
What foods contain high levels of K+ so should be avoided when a patient is on dialysis?
A
Bananas
Chocolate
Potatoes
Avacado
9
Q
Why should a low phosphate diet be observed when on dialysis?
A
It isn’t dialysed well
10
Q
What should be avoided as they are high in phosphate?
A
Ready meals
11
Q
When are phosphate binders taken and what do they do?
A
With meals (6-12 per day):
- Prevent GI phosphate absorption
12
Q
What is the main con of using a Scribner shunt for dialysis?
A
Eventually clogs
13
Q
When is a Scribner shunt still used?
A
For dialysis in AKI or ESRD
14
Q
What veins can a tunnelled venous catheter be inserted into and which is preferred?
A
Jugular (preferred)
Subclavian
Femoral
15
Q
Which of the following can be used in dialysing and AKI patient:
- Scribner shunt
- Fistula
- Tunnelled venous catheter
A
Scribner shunt
Tunnelled venous catheter
16
Q
In which of the following is infection most likely and with what organism:
- Scribner shunt
- Fistula
- Tunnelled venous catheter
A
Tunnelled venous catheter
Staph. aureus
17
Q
If a dialysis site gets infected, what can result?
A
Endocarditis
Discitis
18
Q
How is an infected dialysis line treated?
A
Vancomycin
Line removal
19
Q
How does intradialytic hypotension arise?
A
ICF -> ECF -> Intravascular -> Hypotension
20
Q
If a patient becomes fluid overloaded on dialysis, what can result?
A
Pulmonary oedema
Hypertension
Appearance of LVF
21
Q
What drug should not be given if a patient on dialysis becomes fluid overloaded?
A
Furosemide
22
Q
What are some other complications of dialysis?
A
Blood leaks -> Exsanguination?
Loss of vascular access
Hypokalaemia -> Cardiac arrest
23
Q
What drives water removal across the peritoneal membrane in peritoneal dialysis?
A
High [Glucose] in the dialysate fluid
24
Q
How is continuous peritoneal dialysis carried out?
A
4 bag exchanges per day
Fluid drained then replaced
30 minutes per exchange
25
How is automated peritoneal dialysis carried out?
1 bag left in all day
| Overnight machine drains it in and out (over 9hrs)
26
What are the benefits of continuous peritoneal dialysis?
Simpler
Lower-tech
Cheaper
27
Where can infection arise in peritoneal dialysis?
Peritonitis
| Exit site
28
What are typical contaminants that cause infection in peritoneal dialysis patients?
Staph
Strep
Diphtheroids
29
What gut bacteria can cause infection in peritoneal dialysis patients?
E. coil
| Klebsiella
30
What must we do before treating infection in peritoneal dialysis?
Culture PD fluid
31
What is the treatment for peritoneal dialysis infections?
Intraperitoneal antibiotics:
| - Vancomycin + Gentamicin
32
In what peritoneal dialysis infections must the catheter be removed?
Staph
| Pseudomonas
33
Why can peritoneal dialysis only last so long?
Peritoneal membrane thickens -> Inability to remove enough fluid
34
What can an increased intra-abdominal pressure on standing cause in peritoneal dialysis?
Hernia
35
What symptoms may indicate the need for dialysis?
```
Fatigue
Fluid overload
Vomiting
Itch
Nausea
```
36
How long does the 1st session of haemodialysis usually last?
2 hours
37
Why is the 1st session of haemodialysis shorter?
Prevent disequilibrium syndrome:
- Cerebral oedema
- Seizures
38
Which of the following might indicate the need for withdrawal from dialysis:
- PVD
- Cerebrovascular disease
- CVD
- Cancer
- Liver failure
- Increased patient fragility
- Palliative care
Liver failure
39
How is overt diabetic nephropathy defined?
Persistent albuminaemia:
- 300mg/24hr
- > On >2 occasions
- > 3-6 months apart
40
How does autonomic neuropathy present in diabetes?
Gastroparesis
Silent MI
Urogenital abnormalities
41
What haemodynamic changes are involved in diabetic nephropathy?
1. Afferent arteriolar vasodilation:
- Mediated by vasoactive chemicals (IGF-1)
2. Hyperflitration
3. Increased GFR
42
What causes renal hypertrophy in diabetic nephropathy?
Increased plasma glucose -> Renal growth factors
43
What is a Kimmelstiel-Wilson Lesion?
Nodular diabetic glomerulosclerosis
44
What does proteinuria indicate in diabetic nephropathy?
GBM thickening
| Podocyte dysfunction
45
How can we try and prevent diabetic nephropathy?
Glycaemic control:
| - HbA1c
46
What is the most common causes of renovascular hypertension?
Renal artery stenosis
47
What causes ischaemic nephropathy?
Reduced GFR associated with renal hypoperfusion beyond level of autoregulatory compensation
48
What can ischaemic nephropathy result in?
Renal atrophy
| Progressive CKD
49
What is the prevalence of fibromuscular dysplasia?
4:1000
50
What people are most commonly affected by fibromuscular dysplasia?
Females aged 15-50yrs
51
What percentage of fibromuscular dysplasia cases are familial and how do they tend to present?
10%
| Involving both renal arteries
52
What is fibromuscular dysplasia associated with?
Ehlers-Danlos
53
If fibromuscular dysplasia involves the cerebral arteries, what can happen?
Carotid artery dissection
54
What patients does atherosclerotic renovascular disease tend to affect?
Caucasian males aged >50yrs
55
With what do patients with renovascular disease tend to present?
AKI after ACEi treatment
56
How can patients with atherosclerotic renovascular disease present?
Renovascular hypertension
Flash pulmonary oedema
Microscopic haematuria
Renal bruit
57
Which of the following is not useful in screening for ischaemic renal disease?
- Renal USS
- Renal artery duplex studies
- Urine microscopy
- CT/MRI angiography
- Angiography
Urine microscopy
58
How are the majority of ischaemic renal disease patients treated?
Medical therapy
59
What surgical options are useful in treating ischaemic renal disease?
Angioplasty (+/- stenting)
| Stenting alone
60
When are ACEi inhibtiors contra-indicated in renovascular disease?
Bilateral renal artery stenosis
61
What is myeloma?
Cancer of plasma cells
62
How does myeloma cause disease?
Abnormal plasma cells accumulate in bone marrow:
| - Interfere with normal RBC production
63
What antibody can also be produced by myelomas?
Paraprotein
64
Which of the following is not a sign of myeloma:
- Anaemia
- Recurrent infections
- Haematuria
- Renal failure
- Amyloidosis
- Hypercalcaemia
Haematuria
65
Which of the following is not a symptom of myeloma:
- Bone pain
- Weakness
- Fatigue
- Nausea
- Weight loss
Nausea
66
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%)
```
67
Apart from blood testing, what other investigations can be carried out for myeloma?
Protein electrophoresis
BJP in urine
Lytic lesions on skeletal survey
68
What are the peak ages of myeloma incidence in males and females?
Males - 80 years
| Females - 70 years
69
In what populations is the risk of myeloma doubled?
Blacks
70
What percentage of myeloma patients have renal impairment at presentation?
50%
71
What percentage of myeloma patients need dialysis at presentation?
10%
72
Which of the following is not a renal manifestation of myeloma:
- AKI (secondary to hypercalcaemia)
- Monoclonal Ig Deposition disease
- Glomerulonephritis
- Cast nephropathy
- Amyloidosis
GN
73
What is the pathology of amyloidosis?
Deposition of proteinaceous material in extracellular spaces
74
How is amyloidosis classified?
By type of precursor protein that makes up the main component of the fibrils
75
What are the two classes of renal amyloidoses?
```
Primary amyloid (Amyloid Light-chain [AL])
Secondary amyloid (Serum Amyloid A [AA])
```
76
What is the classical histological appearance of amyloidosis?
Positive Congo-Red staining:
- Showing apple-green birefringence
- > Under polarised light
77
What nephrotoxins need stopped in myeloma with acute renal failure?
NSAIDs
| Diuretics (increase risk of cast formation)
78
How do we treat hypercalcaemic in myeloma?
IV saline for volume resuscitation
| IV pamidronate
79
What can reduce the tumour load in myeloma?
Chemotherapy
| High dose dexamethasone
80
What can plasma exchange do in the treatment of myeloma?
Removes amyloid light chains
81
What is GPA?
Necrotising granulomatosis inflammation
82
Where does GPA most commonly affect?
Respiratory tract
83
How does EGPA usually present?
Asthma (>95%) and eosinophilia
84
What percentage of EGPA patients have skin involvement and what skin features would be present?
66%
Palpable purpura
S/C nodules
85
Is microscopic polyangiitis necrotising?
No
86
Why can microscopic polyangiitis result in pulmonary haemorrhage?
Alveolar capillary involvement
87
In what two small vessel vasculitides is renal involvement more common?
GPA
| MPA
88
How does small vessel vasculitis-related renal disease present?
Haematuria
Proteinuria
AKI
89
How do small vessel vasculitides appear on renal biopsy?
Segmental necrotising GN (crescent)
90
What percentage of SLE patients have renal involvement at presentation?
50%
91
What percentage of SLE patients will have some renal involvement during the course of their disease?
60%
92
What is the most common presentation of lupus nephritis?
Proteinuria
93
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
```
94
What antihypertensive treatment is used in lupus nephritis and what is the target BP?
ACEi/ARBs
| 130/80
95
How do we induce immunosuppression in lupus nephritis?
High dose steroids
Cyclophosphamide/MMF
Azathioprine, Rituximab + Tacrolimus
96
How do we maintain immunosuppression in lupus nephritis?
Steroids
| MMF/Azathioprine
97
Which of the following is not a poor prognostic factor in systemic disease:
- Renal disease
- Female
- Young/Old
- Poor socio-economic status
- Antiphospholipid syndrome
- High disease activity
Female (Being male is a poor prognostic factor)
98
What drugs can cause intrarenal failure?
Gentamicin
Sulphonamides
Aspirin
99
What drugs can cause post-renal failure?
Methysergide
| Chemotherapy
100
Which type of adverse drug reaction has a high mortality?
Type B (Bizarre reactions)
101
What are some examples of Type B adverse drug reactions?
Rashes
Bone marrow aplasia due to Chloramphenicol
Hepatic necrosis due to Halothane
102
Give examples of Type C adverse drug reactions (chronic)?
Steroids -> Cushing's
β-Blockers -> Diabetes
NSAIDs -> Hypertension
103
What types of affects are usually seen in Type D adverse drug reactions?
Teratogenic
| Carcinogenic
104
What are some examples of Type D adverse drug reactions?
Secondary malignancies post-chemotherapy
| Craniofacial abnormalities in kids of women taken isotretinoin
105
What can β-blocker therapy withdrawal result in?
Angina
106
What can steroid therapy withdrawal result in?
Addisonian crisis
107
What drugs does theophylline commonly interact with?
Macrolide antibiotics (Clarithromicin, Eryhtromicin)
108
What drugs do statins commonly interact with?
Macrolides and Fibrates
109
What drugs do ACEi commonly interact with?
Sulphonylureas
110
What drugs does clopidogrel commonly interact with?
PPIs
111
What drugs can exacerbate CHF?
NSAIDs
COX-2
TZDs
112
What drugs can cause urinary retention in BPH?
Decongestants
| Anticholinergics
113
What drugs can worsen constipation?
Calcium channel blockers
| Anticholinergics
114
Potassium rich foods (bananas, oranges and green leafy vegetables) interact with what drugs?
ACEi/ARBs
| K+ sparing diuretics
115
Vitamine E and K rich foods (apples, chickpeas, spinach, nuts, kiwi and broccoli) interact with what drug?
Warfarin
116
Foods that alter pH (chicken, turkey, milk, soy, cheese, yoghurt) interact with what drugs?
Antibiotics
Thyroid medications
Digoxin
Diuretics
117
Which foods interact with cytochome P450 and what drugs can this affect?
Grapefruit, apple, orange and cranberry:
- Statins
- Antihistamines
118
What is the first stage of drug development and what are features of this stage?
Pre-clinical:
- Most efficient
- Least attrition (Financial cost, morbidity/mortality)
119
What phases of drug development are clinical tries and what are some features of these stages?
```
Phases 1-3
Limited sample size:
- Low frequency adverse drug reactions
- Time lag ADR
Exclusion of frail patients
```
120
What are some features of post-marketing surveillance?
Less efficient
High attrition:
- Financial cost, morbidity/mortality
Most data available
121
What is LD50?
The amount of ingested substance/drug that kills 50% of a test sample
122
What is ED50?
The effective dose for 50% of people receiving the drug
123
How is the therapeutic index calculated?
LD50/ED50
124
What is Phase 1 of drug metabolism?
Usually through cytochrome P450:
| - Oxidation, Reduction and Hydrolysis
125
What is Phase 2 of drug metabolism? What does it allow?
Conjugation -> Water soluble
| Enables excretion in urine or bile
126
During what phase of drug metabolism do most adverse drug reaction occur?
Phase 1
127
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
128
Which mutation causing ADPKD results in earlier ESKD?
PKD1 gene mutations
129
What is the pathology of ADPKD?
Large kidneys
Epithelial-lined cysts arise from a small number of tubules
Benign adenomas (25% of kidneys)
130
What is the mean age for hypertension in ADPKD?
31
131
What can cause haematuria in ADPKD?
Cyst rupture
Cystitis
Stones
132
Is ADPKD painful?
Yes it can be
133
What is the most common extra-renal manifestation of ADPKD and when do they appear?
Hepatic cysts ten years after renal cysts
134
What can hepatic cysts in ADPKD cause?
SoB
Pain
Ankle swelling
135
True or false; Hepatic cysts in ADPKD often allow the liver to continue function?
True
136
What percentage of ADPKD patients can suffer from intracranial aneurysms?
4-8%
137
Where do ADPKD-related intracranial aneurysms tend to arise?
Anterior circulation territory
138
When would you screen for ADPKD-related intracranial aneurysms?
If FHx
139
What cardiac disease can result due to ADPKD?
Mitral/Aortic valve prolapse
Valvular disease:
- Collagenous/Myxomatous degeneration
140
What can profoundly increase the risk of diverticular disease in ADPKD?
If they are on dialysis
141
By what percentage is the incidence of abdominal and inguinal hernias increased in ADPKD?
45%
142
What renal changes can be seen on USS of ADPKD?
Multiple, bilateral cysts
| Renal enlargement
143
What genetic investigations can be done into ADPKD?
Linkage analysis
| Mutation analysis
144
Early onset ADPKD presents in what patients?
In utero
| Kids in their 1st year of life
145
How can early onset ADPDK be distinguished from ARPKD?
USS:
| - ARPKD shows congenital hepatic fibrosis
146
How is ADPKD diagnosed in children?
One cysts on USS in a high risk patient
147
How common are cerebral aneurysms in early onset ADPDK?
Rare
148
What is the main treatment for ADPKD?
Rigorous hypertension control
149
What does Tolvaptan do?
Reduces cyst volume and progression
150
If a patient with ADPKD is in renal failure, what treatments can be offered?
Dialysis
Transplant
Cardiovascular and Cerebrovascular disease prevention
151
Who does ARPKD present in?
Young children
152
How common are hepatic lesions in ARPKD?
Very!
153
What is the incidence of ARPKD?
1:20,000
154
What is the genetic linkage in ARPKD?
PKDH1 (On chromosome 6)
155
Where do the cysts arise from in ARPKD?
Collecting ducts
156
Which of the following is not a common presenting sign in ARPKD:
- Kidneys always palpable
- Hypertension
- Recurrent UTI
- Chronic pain
- Slow decline in GFR
Chronic pain
157
What percentage of ARPKD patients die in the 1st year of life?
9-24%
158
If a patient with ARPKD survives the 1st year of life, what is the chance the patient will survive >15 years?
80%
159
What is Alport's syndrome?
Hereditary nephritis due to a disorder of Type IV collagen matrix
160
What percentage of patients with ESKD have Alport's syndrome?
1-2%
161
What is the most common inheritance of Alport's syndrome?
X-linked (85%)
162
What is the common gene mutation in Alport's syndrome and what does it cause?
COL4A5:
| - Deficient collagenous matrix
163
What is the characteristic feature of Alport's syndrome?
Haematuria
164
When does proteinuria occur in Alport's syndrome and what is it a sign of?
Later
| Bad prognostic indicator
165
What are some extra-renal manifestations of Alport's syndrome?
Sensorineural deafness
Ocular defects:
- Anterior lenticonus -> Conical protrusion of lens
- Keratoconus -> Conical corneal protrusion
Leiomyomatosis of oesophagus/genitals (rare)
166
When should Alport's syndrome be suspected?
Haematuria +/- Hearing loss
167
How does Alport's syndrome appear on renal biopsy?
Variable thickness GBM (characteristic)
| Lamina densa splitting
168
How is Alport's syndrome treated?
```
Aggressive treatment of:
- BP
- Proteinuria
Dialysis
Transplant
```
169
What is Anderson Fabrys Disease?
Inborn error of glycosphingolipid metabolism:
- α-galactosidase A deficiency
- Lysosomal storage disease
170
What type of inheritance is Anderson Fabrys Disease?
X-linked
171
Which of the following does Anderson Fabrys Disease not affect:
- Kidneys
- Heart
- Liver
- Lungs
- Eryhtrocytes
Heart
172
How will a renal biopsy appear in Anderson Fabrys Disease?
Concentric lamellar inclusions within lysosomes
173
What is the main cutaneous feature of Anderson Fabrys Disease?
Angiokeratomas
174
What are some cardiovascular features of Anderson Fabrys Disease?
Cardiomyopathy
| Valvular disease
175
What are some neurological features of Anderson Fabrys Disease?
CVA
| Acroparaesthesia
176
How can Anderson Fabrys Disease be diagnosed?
Plasma leukocyte α-GAL activity
Biopsy:
- Renal
- Skin
177
What is an angiokeratoma?
A benign cutaneous lesion of capillaries, resulting in small marks of red to blue color; characterized by hyperkeratosis
178
How is Anderson Fabrys Disease treated?
Fabryzyme
| Complication management
179
What pattern of inheritance does Medullary Cystic Kidney show?
Autosomal dominant
180
What is the pathology behind Medullary Cystic Kidney?
Abnormal renal tubules -> Fibrosis
| Cysts in the corticomedullary junction and medulla
181
What size are kidneys in Medullary Cystic Kidney?
Normal/Small
182
How is Medullary Cystic Kidney diagnosed?
FHx
| CT
183
When does Medullary Cystic Kidney present?
~28 yers of age
184
What is the best treatment for Medullary Cystic Kidney?
Transplant
185
What sort of inheritance does medullary sponge kidney show?
Sporadic
186
What is the pathology behind medullary sponge kidney?
Dilatation of collecting ducts
187
What do the cysts have in medullary sponge kidney?
Calculi
188
How is medullary sponge kidney diagnosed?
IV urography
OR
Contrast-enhanced CT
