Diabetes

Question 1

How do you treat diabetes

Answer 1

1.st line: Metformin

2nd line: DPP-4 inhibitor, SGLT2 inhibitor, Glp1 receptor agonist (these reduce death)

Question 2

What are clinical feature of diabetic nephropaty

Answer 2

Hypertension

proteinuria

derranged kidney function

Question 3

What is the best way to check for diabetic nephropathy?

Answer 3

look at proteinuria first thing

creatinine goe up higher later

Question 4

What are you particularly at risk of if you have diabetes with diabetic nephropathy?

Answer 4

much higher risk of cardiovascular events

Question 5

What are the parts of the kidney that are impacted by diabetic nephropathy

Answer 5

1. glomerular:
   
   1. Mesangial expansion
   2. basement membrane thickening
   3. Glomerulosclerosis
2. vascular
3. tubulo interestial

Question 6

How long does it take for someone with diabetes to develop reanal failure

Answer 6

30-40 years

Question 7

WHat are risk factors that impact whether someone get diabetic nephropathy

Answer 7

age at which you get diabetes

racial factors

age of presentation

loss due to cardiovascular morbidity

Question 8

What are ways to prevent the onset of diabetic nephropathy in someone with diabetes

Answer 8

1. diabebetic control
2. blood pressure control
3. suppression of RAAS
4. stop smoking

Question 9

What are the antihypertensives that you give to diabetics

Answer 9

ACE inhibitor

Question 10

If someone get’s a cough with an ACE inhibitor and is diabetic, what is the next drug you would give

Answer 10

ARB

Question 11

Which of the following are feature of diabetic nephropathy:

A. affects all patient with diabetes over time

B associated with decreased BP

C. progressively increasing proteinuria

D. Unrelated to glycaemic control

E, Associated with a low risk of cardiovascular events

Answer 11

C. progressively increasing proteinuria

Question 12

Regarding ACE inhibition in patients with diabetes

A. ACE inhibitors cause improvement in the creatinine within days of starting

B. Ace inhibitors cause an increase of the creatinine within days of starting

C. ACE inhibitors increase microalbuminuria

Answer 12

B

Question 13

What happens if you give somone with renal artery stenosis an ACE inhibitor?

Answer 13

fall in GFR

Question 14

Regarding ACE inhibitors in patients with diabetes

A. ACE inhibitors are useful in patients with diabetes and resultant renal artery stenosis

2. ACE inhibtors increase microalbuminuria
3. ACE inhibitors prevent end stage renal failure
4. ACE inhibitors cause hypokalaemia

Answer 14

3. ACE inhibitors prevent end stage renal failure

Question 15

if you give some an ACE for their diabetic nephropathy what happens to their kidney function

Answer 15

inititally drops off massively but then it plateau and the fall is much less than without and therefore over many years it is more favourable

Question 16

What should you do if someone has been given an ACE inhibitor and they have renal artery stenosis

Answer 16

you have to take them off it

AND THEN

call a nephrologist might need to be dialised for a while

BUT they will fully recover

Question 17

What are the problems/ implications of renal failure

Answer 17

1. Electrolyte imbalance: hyponatraemia, hyperkalaemia
2. ACIDOSIS
3. fluid retention
4. retention of waste products: urea, creatinine, urate, phosphate, middle molecules
5. LESS secretion of EPO and Vitamin D

Question 18

WHat are symptoms of renal failure

Answer 18

tiredness - anaemia (lack of EPO)

SOB and oedema

Pruritus - renal bone disease (lack of vit. D)

nocturia, feeling cold, twitching (later on)

poor apetite, nausea, loss of taste, weight loss

Question 19

What are the lack of kidney functions and how do they manifest

Answer 19

Hyperkalaemia- arrthmias, cardiac arrest

Pulmonary oedema- fluid retention

Nause and vomitting- acidosis

Malnutrition cachexia - loss of apetite and taste

Fits & increasing coma - hypnatraemia

DEATH

Question 20

What are renal replacement therapies?

Where are they done?

Answer 20

Dialysis

• haemodialysis:
  
  • HOSPITAL based but can be done at home
• peritoneal dialisis
  
  • HOME treatment

Transplantation

Question 22

What are the aims of renal replacement therapy

Answer 22

correct electrolytes

remove waste product

restore fluid balance

improve symptoms

maintain quality of life

Question 23

When do you refer for renal replacement therapy?

Do you start it then?

Answer 23

eGFR of below 20

No just discuss and organise

and then you may start at 10ml/min (benifits outweigh the risks)

Need to start at 6 or less

Question 24

What do you need to tell the patient about

Answer 24

Risks of renal failure

types of renal replacement failure and then establish the access

Question 25

What are the different accesses for renal replacement therapy

Answer 25

fistula PD catheter transplant assesment

Question 26

At what eGFR does someone have to be on dialysis? At what eGFR woudl it be beneficial?

Answer 26

At what eGFR does someone have to be on dialysis? 10 At what eGFR woudl it be beneficial - 6

Question 27

What are the risks adn benifits of dyalisis?

Answer 27

Benifit improve uraemic syndrome (reduce pruritus, nausea and tiredness) correct fluid balance (less SOB and oedema) Avoid life threatning complication like acidosis, hyperkalaemia and pulmunary oedema resistant to diuretics RISKS infection hypotension reduces quality of life (travel, family life)

Question 28

What does dialysis not treat

Answer 28

anaemia vitamin D (renal bone diasease) AND comorbidities SLE, diabetes and vascular disease

Question 29

What are the 2 different type of dialysis

Answer 29

**haemodialysis**: 3 times a week - 4 hours (needs a fistula and catheter) **peritoneal dialysis:** Home base: daily and continuous, less haemodynamic stress but need a peritoneal access GOOD becauses avoid the swings, done at home and less dietary and lfuid restrictions

Question 30

WHat are the benifits and risks of transpantation

Answer 30

benefits: 1. better renal replacement - because also good for anaemia and renal bone disease 2. Costs less in long term 3. prolongues life 4. good for quality of life RISKS: 1. older and sicker patients not eligible 2. immunosuppression (increased infection and malignancy) 3. surgical complications 4. worse off if the transplant fails

Question 31

how do you predict survival of patients on dialysis? What do it take into account

Answer 31

body mass index heart failure peripheral vascular disease dysrhythmia active malignancy severe behavioural disorder total dependency unplanned dialysis

Question 32

Is dialysis always beneficial?

Answer 32

no study where people over 75 year of age with 2 comorbidities were put on dialysis SURVIVAL Was the same

Question 33

What BMI is considered high (obese) in white and asian people

Answer 33

white - 25 asian- 23.9

Question 34

SOme is obese what would you advise him regarding gym A. encourage regular exercise B. ban him from doing any exercise at all and recommend rest adn repeat of his BP C. advise him to see his GP beofre allowing him to exercise in the gym D. refer him to casualty for blood pressure control

Answer 34

A. encourage regular exercise

Question 35

if someone has hypertension what would you look for

Answer 35

Fundoscopy

Question 36

What happens in the different grades of hypertension?

Answer 36

Grade 1: silver wiring Grade 2: AV nipping Grade 3: flame shaped haemorrhage Grade 4: papilloedema

Question 37

What could papilloedema indicate

Answer 37

high ICP- possibly brain tumour hypertension

Question 38

WHat are feature of long standing hypertension exist

Answer 38

left ventricular hypertrophy (ECG) feel a heave hear a bruit hear an S4

Question 39

WHat grade is this

Answer 39

grade 3 see flame haemorrhage

Question 40

What are 6 causes of hypertension

Answer 40

1. **Conn's** 2. Cushing's 3. Phaechromocytoma 4. renal artery stenosis 5. Acromegaly 6. co arctation of the aorta 7. essential

Question 41

What are investigation would you like to do? if someone presents with hypertension

Answer 41

* FBC * **_U&E low K+ high Sodium_** * ECG look for LVH * Urinalysis (renal disease and nephritis) * Fasting glucose * Lipids

Question 42

What percentage of people have secondary hypertension

Answer 42

10%

Question 43

What are specific investigations to diagnose secondary causes of hypertension

Answer 43

renin aldosterone ration 24 hour urine for catecholamines 24 hour urine cortisol glucose tolerance test

Question 44

Someone presents with renin 0.4 (1.1-4.5) aldosterone 1600 (100-450) 24 hour urine catecholamine normal What does he have

Answer 44

Conn

Question 45

How do you treat conn's

Answer 45

surgery remove it

Question 46

patient presents with renin: 7.4 (1.1-4.5) aldosterone: 900 (100-450) 24 hour urine catecholamines is normal What does this patient have

Answer 46

renal artery stenosis

Question 47

What is the gold standard way of diagnosing renal artery stenosis

Answer 47

Digital subtraction angiogram

Question 48

what does this patient have? Renin: 2.4 (1.1 -4-5) Aldosterone: 300(100-450) 24 hour urine for catecholamines RAISED

Answer 48

phaechromocytoma

Question 49

how does phaechromocytoma present?

Answer 49

anxiety palpitation headache sweating

Question 50

What is the treatment for phaechromocytoma?

Answer 50

MEDICAL EMERGENCY ## Footnote **alpha blockade**

Question 51

How do you manage a phaechromocytoma

Answer 51

1. alpha blockade (rehydrate if needed) 2. beta blockade 3. localise the lesion 4. surgery (many weeks after alpha blockade)- laprascopic adrenalectomy

Question 52

What does an MIBG scan show

Answer 52

is a radioactive scan and shows where the tumour is the bladder always lights up

Question 54

How do you treat essential hypertension?