Kidney Disease Flashcards
(95 cards)
1
Q
What is chronic kidney disease
A
Abnormal kidney function and/or structure
Can have normal function (e.g. U&E are fine) but will still have CKD if there is a structural problem with the kidney
2
Q
What does CKD increase your risk of
A
Acute kidney injury
Falls
Frailty
Mortality - particularly from CVD
3
Q
What conditions does CKD often co-exist with
A
cardiovascular disease
diabetes
4
Q
How do you diagnose CKD
A
Raised creatinine or reduced GFR after more than 90 days
Need 2 samples at least 90 days apart
5
Q
What are the stages of CKD
A
G1 - normal function but structural or urine finding G2 - mild reduction in function G3 - moderate reduction G4 - severe reduction G5- renal failure
6
Q
What is the significance of albumin in the urine
A
It is a marker or endothelial or vascular disease
Its a glomerular protein
7
Q
What does the albumin:creatinine ratio mean
A
Measure of glomerular damage
The higher the ratio the worse the disease
8
Q
How would you follow up someone with AKI
A
Advise that they are at risk of CKD developing
Monitor for at least 2-3 after the AKI episode but should probably do lifetime
9
Q
list risk factors for CKD
A
Diabetes Hypertension AKI CVD Structural kidney disease Family History
10
Q
what is the definition of accelerated CKD progression
A
Sustained decrease in GFR of 25% or more and a change in GFR category within a year
11
Q
What can chronic NSAID use do to the kidneys
A
Can cause AKI
12
Q
What is the target BP for people with CKD
A
Systolic below 140mHg
Diastolic below 90mmHg
13
Q
What is the target BP for people with CKD and diabetes (or ACR of 70 or more)
A
Systolic below 130mmHg
Diastolic below 80mmHg
14
Q
How do you manage ACEi or ARB treatment in CKD
A
DO NOT alter does if the GFR decrease is less than 25%
or if serum creatinine increase is less than 30%
15
Q
How do you manage statin therapy in CKD
A
Offer Atorvastatin 20mg for CVD prevention
Increase dose if there isn’t sufficient reduction
16
Q
List the 3 most common causes of CKD
A
Diabetes
Hypertension
Glomerulonephritides - primary or secondary
17
Q
If you find FSGS what must you do
A
Test for blood borne viruses
18
Q
List less common causes of CKD
A
Vascular disease - macro and micro
Tubulointerstitial problems
Calculi
Prostatic and Bladder cancer
19
Q
List clinical signs of CKD
A
Anaemia - pallor Weight loss Uraemia: - lemon yellow - uremic frost on skin - twitching - encephalopathic flap - confusion - kussmaul breathing
20
Q
List symptoms of CKD
A
nausea and vomiting anorexia weight loss fatigue Itch restless legs and muscle twitches confusion Pain - bone, nerve, visceral etc depression
21
Q
List renal consequences of CKD
A
Local pain, haemorrhage, infection
Haematuria or proteinuria
Hypertension
Impaired salt, water electrolyte handling
22
Q
List extra renal consequences of CKD
A
CVD
Mineral and bone disease
Anaemia
Nutrition
23
Q
How do you manage CKD
A
Renal replacement therapy - dialysis or transplant
Conservative - will die eventually
24
Q
How can you reduce CV risk
A
Smoking cessation Weight loss and exercise Limited salt intake Control hypertension Statin
25
How does CKD lead to bone disease
Changes in minerals - e,g, calcium, phosphate
| Increased fracture risk, pain and expansion
26
What are the consequences of mineral bone disease in CKD
```
Bone pain
fractures
CV events
Vascular calcification
Lower QoL
```
27
What dietary changes can help with CKD-MBD
Reduce phosphate, salt, potassium, fluids
28
What medications can help with CKD-MBD
Phosphate binders
| Active Vit D - alfacalcidol
29
How can you treat renal anaemia
Iron therapy
| Try oral first but if it doesn't work use IV
30
What 3 concepts are involved in dialysis
Diffusion
Convection
Adsorbtion
31
What is the function of dialysis
Allows removal of toxins which build up in end stage renal disease (urea, potassium, sodium)
Allows infusion of bicarbonate
32
How does haemodialysis work
Need good vascular access
Filter through the machine which has lots of microfilaments
Dialysate runs through machine which sets up gradient needed to remove toxins
Also sets up pressure gradient to remove some water
33
what does adsorption mainly affect
affects the plasma proteins and solutes that are bound to them
They stick to the membrane surface and then removed
34
How does hemodiafiltration work
mainly by convection
Add a huge volume of ultra-pure filtrate so that the pressure gradient helps remove more
Some diffusion occurs
35
Which factors affect efficacy of haemodiafiltration
```
Water flux - rate and vol
Membrane pore size
Pressure difference across membrane
Viscosity of fluid
Size, shape and charge of molecules
```
36
How much fluid is used in high volume HDF
Replacement volume of more than 20 litres
37
How often does someone get dialysis
Minimum of 4 hours, 3 times a week
| More effective with longer treatment time
38
What diet restrictions are put on a dialysis patient
```
Fluid - around 1l per day
Low salt diet
Low potassium diet
Low phosphate diet
Affects what you eat and how you cook etc
```
39
What is a tunnelled venous catheter
Catheter inserted into a large vein such as IJV
| Can stay in for 2-3 weeks
40
What are the pros of tunnelled venous catheter
Easy to insert
| Can be immediately used
41
What are the cons of tunnelled venous catheter
High risk of infection
Can become blocked
Can cause damage (stenosis/ thrombosis) to central veins making future line insertion difficult
42
How would you diagnose and treat a catheter infection
Blood cultures
FBC and CRP
Swab exit site
Treat with vancomycin and gentamicin
Line removal or exchange
43
What pathogen most commonly infects venous catheters
staph aureus
44
What is the gold standard of dialysis vascular access
Arteriovenous Fistula
| Surgically connect artery and vein
45
List common sites for AV fistula
Radio cephalic
Brachio cephalic
Brachio basilic
46
What are the pros of AVF
Good blood flow
| Less likely to get infected
47
What are the cons of AVF
Requires surgery
needs 6-12 weeks before use
Can limit the blood flow to distal arms
Can thrombose or stenose
48
How can grafts be used in dialysis
Can put in a arteriovenous grfat if natural vein isn't good enough
HeRO graft - connect graft to right atrium
49
List potential complications of dialysis
```
Hypotension - dizziness or LoC
Haemorrhage
Loss of vascular access
Arrhythmia
Cardiac arrest
```
50
How does peritoneal dialysis work
Solute removal by diffusion of solutes across the peritoneal membrane
Also creates an osmotic gradient to remove water
Can be done at home Either several bags a day or one that stays in all day - drained at night
51
What organisms commonly cause infection in PD
Contamination of site - staph, strep or diptheriods
| Gut bacteria translocation - E.coli or klebsiella
52
How do you treat infection in PD
Culture the PD fluid
Give intraperitoneal antibiotics
may need to remove the catheter
53
What are some potential complications of PD
Infection - peritonitis
Membrane failure - cant remove enough water/solutes
Hernias
54
what blood test results suggest dialysis is needed
Resistant hyperkalaemia
eGFR < 7 ml/min
Urea > 40 mmol/L
Unresponsive metabolic acidosis
55
What symptoms may suggest that dialysis is needed
```
Nausea
Anorexia
Vomiting
Profound fatigue
Itch
Unresponsive fluid overload
```
56
How do you start HD
Gradually build up
| stat at 90-120 mins then increase slowly to 4hrs
57
What can happen if you start dialysis too fast
Can lead to disequilibrium syndrome
| Cerebral oedema and possible confusion, seizures and occasionally death
58
How do you start up PS
Start with smaller fill volumes and gradually increase
| Regular clinic follow ups
59
Why might you withdraw from dialysis
Haemodynamic instability
Progressive dementia
Inability to remain on therapy for full duration due to agitation
Cardiovascular event
Terminal cancer
Increasing fraility and inability to cope at home
60
What happens when you withdraw someone from dialysis
Palliative care
61
List common symptoms of kidney disease
```
Loin pain
Polyuria and nocturia
Haematuria - micro or painless macro
Proteinuria
Hypertension
Fluid retention
Bone pain
Signs of anaemia
```
62
Why do people with kidney disease become anaemic
Kidneys are responsible for producing erythropoietin
| When they are damaged it affects this and it becomes defective
63
How does kidney disease lead to bone pain
Vitamin D metabolism and phosphate excretion become abnormal
This leads on to bone pain
64
What examination finding suggest kidney disease in the asymptomatic patient
dipstix microscopic haematuria &/or proteinuria
reduced estimated GFR on biochemical screen
raised BP
incidental findings on abdominal imaging
65
List drugs that can affect renal function
ACEi, ARB, diuretics
NSAIDs
Antibiotics
PPI's
66
How do NSAIDs affect the kidneys
They decrease glomerulus pressure and decrease GFR
| This causes fluid retention
67
Which antibiotic is nephrotoxic
Gentamycin
68
Why is retinopathy sometimes seen in kidney disease
It is a sign of DM or hypertension
| Both of which can cause kidney disease
69
What is accelerated hypertension
A medical emergency
Diastolic BP>120mmHg
Seen in young or sick patients
70
List symptoms of accelerated hypertension
```
Papilloedema
Encephalopathy
Fits
Cardiac failure
Acute renal failure
```
71
How might vasculitis present in the skin
Non-blanching rash
| Not raised
72
How can you quantify urinary protein
24hr urine collection
| Urine protein/creatinine ratio - can be done on spot test
73
Describe the different ranges for proteinuria
Low grade - <1g per day
Heavy 1-3g per day
Nephrotic range >3g per day
74
What does a red cell urinary cast indicate
Pathology - usually nephritic syndrome
75
What does a leucocyte urinary cast indicate
Infection or inflammation
76
What does a granular urinary cast indicate
Indicator of chronic disease
77
What is the ECG sign of hyperkalaemia
Tall tented T waves
78
What causes nephrotic syndrome
Glomerular disease
79
What are the symptoms of nephrotic syndrome
Proteinuria >3g per day
Hypoalbuminemia
Hypercholesterolaemia - due to overwork of liver
Oedema - everywhere!!
80
What are the signs of nephritic syndrome
Oliguria
Oedema
Hypertension
Active urinary sediment
81
What causes nephritic syndrome
It is the clinical syndrome of glomerulonephritis
82
What gives better survival - dialysis or transplant
Transplant - all sources are better than dialysis
83
List the different types of transplant
Deceased heart beating donors - brain dead
Non-beating heart donor - must be done fast
Live donation
84
List contraindications for kidney transplant
```
Malignancy
Active HCV or HIV infection
Untreated TB
Severe IHD
Active vasculitis
Severe peripheral vascular disease
Hostile bladder
```
85
Patients must have a reasonable life expectancy to be suitable for transplant - true or false
True - must be more than 5 years
86
How do you match a kidney to a recipient
By blood group
| HLA typing - good match gives lower chance of rejection (especially in case of second transplant)
87
List potential sensitising events for rejection of a transplant
Blood transfusion
Pregnancy or miscarriage
Previous transplant
They will have pre-formed antibodies to non-self antigens
88
How are kidneys allocated
Paediatrics get the first offer
Then goes to an ideal match
Then a favourable match - e.g. one criteria isn't perfect
Then any other match
89
how does paired donation work
2 sets of live donors and recipients
The donors aren't a match for their loved ones but are compatible with the other pairs recipient
This way both recipients get a kidney and both donors give one - just to the opposite pair
90
Where is a new transplant placed
New kidney is grafted on to the iliac vessels - lower down
| Native kidney does not come out unless causing infection or polycystic
91
Describe the different levels of graft function
Immediate graft function - good urine output and falling creatine etc immediately
Delayed - get acute tubular necrosis and may need dialysis for a while but starts working in 10-30 days
Primary non function - never works
92
What are the different types of rejection
Hyperacute - caused by preformed antibodies
Acute rejection - cellular or antibody mediated
Chronic - antibody mediated with slow decline in function
93
what type of rejection is salvageable
Acute
| Can be treated with increased immunosuppression
94
Describe the immunosuppressive therapy needed in transplant patients
Start with IL-2 antagonist as induction
Prednisolone Iv in op
Then give prednisolone, tacrolimus and MMF as maintenance
95
List general complications of immunosuppression
Infection - UTI and LRTI
CMV disease BK Nephropathy
Cancer
Post transplant lymphoproliferative disease - EBV
