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Year 2 - Renal (DP) > Clinical (Week 5) > Flashcards

Flashcards in Clinical (Week 5) Deck (188):
1

How quickly does blood flow through the dialysis machine?

300ml/min

2

The following ions are in the dialysate, but are they in higher or lower concentrations than the patients blood:
- Na+
- Bicarbonate
- K+
- Glucose

Na+ is lower
Bicarbonate is higher
K+ is lower
Glucose is about equal (if not slightly higher)

3

How is water removed from the patient?

Dialysate hydrostatic pressure

4

Why is pure water used for the dialysate?

No cytokines, bacteria or toxins present that may damage the patients

5

How efficient is dialysis?

Not very:
- 10-12ml/min/1.73m^2

6

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)

7

If a patient on dialysis is anuric, what must their fluid intake be restricted to?

1L per day

8

What foods contain high levels of K+ so should be avoided when a patient is on dialysis?

Bananas
Chocolate
Potatoes
Avacado

9

Why should a low phosphate diet be observed when on dialysis?

It isn't dialysed well

10

What should be avoided as they are high in phosphate?

Ready meals

11

When are phosphate binders taken and what do they do?

With meals (6-12 per day):
- Prevent GI phosphate absorption

12

What is the main con of using a Scribner shunt for dialysis?

Eventually clogs

13

When is a Scribner shunt still used?

For dialysis in AKI or ESRD

14

What veins can a tunnelled venous catheter be inserted into and which is preferred?

Jugular (preferred)
Subclavian
Femoral

15

Which of the following can be used in dialysing and AKI patient:
- Scribner shunt
- Fistula
- Tunnelled venous catheter

Scribner shunt
Tunnelled venous catheter

16

In which of the following is infection most likely and with what organism:
- Scribner shunt
- Fistula
- Tunnelled venous catheter

Tunnelled venous catheter
Staph. aureus

17

If a dialysis site gets infected, what can result?

Endocarditis
Discitis

18

How is an infected dialysis line treated?

Vancomycin
Line removal

19

How does intradialytic hypotension arise?

ICF -> ECF -> Intravascular -> Hypotension

20

If a patient becomes fluid overloaded on dialysis, what can result?

Pulmonary oedema
Hypertension
Appearance of LVF

21

What drug should not be given if a patient on dialysis becomes fluid overloaded?

Furosemide

22

What are some other complications of dialysis?

Blood leaks -> Exsanguination?
Loss of vascular access
Hypokalaemia -> Cardiac arrest

23

What drives water removal across the peritoneal membrane in peritoneal dialysis?

High [Glucose] in the dialysate fluid

24

How is continuous peritoneal dialysis carried out?

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