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Human Diseases Yr4 > Renal > Flashcards

Renal Flashcards

1
Q

What 3 parts are the glomerular filtration barrier made up of?

A
  • Epithelial cells of the bowmans capsule
  • Glomerular basement membrane
  • Fenestrated capillary endothelium
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2
Q

What forms the visceral layer of renal corpuscle in the glomerulus?

A

Podocytes

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3
Q

a) What is the glomerular filtration rate?

b) What methods are used to assess GFR?

A

a) The sun of the filtration rates in all the functioning nephrons - the volume of plasma filtered by the glomerulus per unit of time
b) - Creatine clearance - Plasma creating concentration - Estimation equation e.e.g Cockrofts Gault, MDRD

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4
Q

What is a healthy

a) GFR for women
b) GFR for men
c) Urine output

A

a) 95 +/- 20 ml/min
b) 120 +/- 25 ml/min
c) 2-3 L/day

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5
Q

What is creatine and where is it filtered?

A

Derived from metabolism of skeletal muscle and meat

Freely filtered across glomerulus and 15% from tubular secretion by proximal tubule

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6
Q

What is the formula for creatine clearance?

A

Urine creatine concentration x Volume / Plasma creatine concentration

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7
Q

What are the limitations of using creatine clearance?

A
  • Incomplete urine collection

- Increased creatine secretion from tubule in renal impairment

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8
Q

If GFR is low, what will the level of creatine be?

What is the shape of the curve of creatine against GFR?

A

Creatine high

Exponential (L shape)

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9
Q

Who doesnt glomerular filtration rate work in?

A
  • Children
  • Amputees
  • Pregnancy
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10
Q

Describe stage 1 and stage 2 of chronic kidney disease (CKD)

A

1 - GFR 90+, normal function, may have structural abnormalities, observe and control BP
2 - GFR 60-89, mildly reduced function, observe and control BP and address risk factors

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11
Q

Describe Stage 3 CKD

A
  • GFR 30-59
  • Pt asymptomatic
  • Creatine marginally raised
  • Tend to retain solutes, become hypertensive
  • Reduced vit D and calcium
  • Reduced Epo, become anaemic
  • Observe, BP control and modify drug doses, avoid nephrotoxins
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12
Q

Describe Stage 4 CKD

A
  • GFR 15-29
  • Creatine 250-600umol/L
  • Tired, pale, non-specifically unwell
  • Need dietary restriction, phosphate binders, vit D and erythropoeitin
  • Usually need anti-hypertensive drugs and diuretics
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13
Q

Describe Stage 5 CKD

A
  • GFR <15
  • Creatine >700
  • End stage renal failure requiring dialysis if GFR<5mls/min or creatine >900
  • Pale, tired, unwell
  • Anorexic, nausea, vomiting, uraemic fetor, itch
  • Confusion
  • Fluid retention, oedema, congestive cardiac failure
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14
Q

What condition can cause chronic renal failure?

A

Diabetes (affects small blood vessels)

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15
Q

Give examples of drugs in CRF pts:

a) that are renally excreted so may accumulate
b) that have an altered protein binding
c) that are nephrotoxic so worsen renal function

A

a) Opiates
b) Increased protein binding = basic drugs e.g. lignocaine. Decreased protein binding = acidic drugs e.g. Phenytoin
c) NSAIDS, Gentamicin

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16
Q

What are the effects of uraemia on the haematology of CKF pts?

A
  • Prolonged bleeding time
  • Normal platelet count but disturbed platelet function
  • Increased bruising
  • Check pt not on aspirin or clopidogrel
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17
Q

How is bleeding time improved in CKF pt with uraemia?

A

Dialysis or increased haematocrit (with Erythropoeitin)

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18
Q

Name 4 effects of chronic renal failure

A
  • Pulmonary and Peripheral oedema (due to salt and water retention)
  • Restless Leg syndrome - cramps, tremors and twitches
  • Hormonal imbalance
  • Increased cardiac instability (severe metabolic acidosis, hyperkalaemia and hypocalcaemia)
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19
Q

What is the definition of acidaemia?

A

A pH of <7.2 (HCO3- <16mmol/L) that impacts cellular and cardiac function

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20
Q

What medical intervention can offer a bridge in pts with acidaemia until dialysis is available?

A

Sodium bicarbonate

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21
Q

What are additional causes of acidaemia?

A
  • Lactic acidosis
  • DKA
  • Poisoning
22
Q

What happens if a patient misses dialysis session?

A

Lungs can fill with fluid and become breathless - pulmonary oedema

23
Q

In what circumstance should anticoagulation be avoided in dialysis?

A

Pericardial effusion as it will reduce the risk of pericardial bleeding

24
Q

For Haemodialysis

a) How often?
b) Where is the fistula connected?
c) What anticoagulation is used?
d) What does it achieve?

A

a) 4 hrs 3 x week
b) Tunneled intrajugular neckline or arm arteriovenous (Brachial AV)
c) Heparin
d) Fluid removal and biochemical correction

25
Q

What are the issues with AV fistula?

A

Haematoma and Infection

26
Q

What are the 2 types of vascular access lines for dialysis?

A

Temporary line ‘Vascath’ (high infection risk, internal jugular, lasts 1-2 yrs)
Tunelled lines ‘Tesid’ (cuff reduces infection)

27
Q

What are the pros and cons of continuous ambulatory dialysis (CAPD)?

A 
\+ Gentle, good biochemical control 
\+ No anticoagulation 
- Weight gain with glucose as osmotic agent 
- Peritonitis 
- Peritoneal membrane failure over time
28
Q

What are the complications of uraemia and dialysis?

A
  • Hypotension
  • Cramp
  • Anaemia
  • Vascular calcification
  • Increased risk of heart disaes
  • Amyloidosis as a consequence of beta-2-microglobulin accumulation
29
Q

Who does not require antibiotic prophylaxis?

A
  • Immunosupressed transplant patients
  • Dialysis patients
  • CRF patients with no valve/endocarditis risk
  • CAPD or tunelled central line patients
30
Q

Who does require antibiotic prophylaxis? What cover is given?

A
  • Haemodialysis patients with a prosthetic valve or other endocarditis risk
  • Amoxicillin 3g 1 hr before procedure or IV Vancomycin or Gentamycin for dialysis pts, Clindamycin for penicillin allergies
31
Q

What rare inherited syndrome is associated with kidney disease and also causes bifid tongue?

A

Orofacial digital syndrome

32
Q

What drugs that are used in immunosupression for renal transplants cause gingival hypertrophy?

A
  • Tacrolimus/Fk506 and Cyclosporin A/Neoral
33
Q

What drugs that are used in immunosupression for renal transplants cause hyperlipidaemia, delayed wound healing and stomitis?

A

Sirolimus or Rapamycin

34
Q

Which immunosuppressive drugs used in renal transplant pts inhibit purine synthesis?

A

Azathioprine and mycophenolate mofetil (MMF)

35
Q

What is the MOA of cyclosporin and tacrolimus?

A

Calcineurin inhibitor which blocks activation of T cells and so of cytokines such as IL2

36
Q

What is a clinical feature of nephrotic syndrome?

A

Bilateral periorbital oedema

37
Q

What is nephrotic syndrome?

A
  • Massive proteinuria with hypoalbuminaemia

- Leaky kidneys so low levels of protein in intravascular compartment

38
Q

What are the clinical implications of treating a patient with nephrotic syndrome?

A
  • Taking long term steroids
  • Electrolyte disturbances and steroid treatment lead to risk of infection
  • Pts more likely to have cardiovascular disorders
39
Q

What is the most common cause of end stage renal failure?

A

Diabetic nephropathy

40
Q

What should you be thinking of if treating a patient with a renal transplant?

A
  • Steroid cover for certain procedures that are physiologically stressful
  • No antibiotic cover but bear in mind for M.O.S
  • Predisposition to infections: oral candidosis, herpes simplex, zoster virus - in some cases low dose aciclovir given
  • Greatly increased chance of malignant disease e.g. skin cancer and lymphomas as immunosuppressed
41
Q

Describe the feedback loop that makes renal osteodystrophy a universal feature of CKD

A

Increase in plasma phosphate levels
Supression of plasma calcium
Elevated parathyroid hormone levels (PTH)
Calcium taken out of bones

Calcium further compromised by disruption in Vit D metabolism

42
Q

Renal osteodystrophy in CKD pts can also be secondary to use of which drug?

A

Steroid therapy (osteoporosis and bisphosphonate therapy)

43
Q

Why does anaemia occur in CKD pts?

A

Failure of production of erythropoietin by kidneys
Renal loss of RBCs
Marrow fibrosis
Increased RBC fragility with early destruction
Reduced platelet count and function

44
Q

What are the features of anaemia of chronic disease seen in CKD pts?

A
  • Normochromic
  • Normocytic
  • Hb 70g/L (normal is 180g/L)
  • Reduced platelet count/functioning
45
Q

When is the optimal time for dental treatment after dialysis?

A

1 day - heparin worn off and renal function optimal

46
Q

Why might there be problems with haemostasis in a CKD pt?

A
  • Impaired platelet count and adhesion
  • Decreased von Willebrands factor
  • Decreased thromboxane
  • Prostacyclin levels increased (vasodilation)
  • Heparinisation (heparin wears off quickly)
47
Q

What may you notice about a CKD pt on examination?

A

E/O - Fistula, Oedema, Steroid facies (moon face), swelling of major salivary glands/sialosis (dialysis pts)
I/O - Increased incidence of ulceration and infections, gingival hyperplasia (cyclosporin), palatal and buccal keratosis sometimes seen (xerostomia)

48
Q

What would you notice O/E of a child with CKD?

A
  • Decreased growth

- Delayed tooth eruption and enamel hyperplasia (due to metabolic disturbances)

49
Q

Which drugs should you avoid in CKD pts?

A
  • Tetracyclines (other than doxycycline)
  • NSAIDs (unless mild)
  • Gentamycin (nephrotoxic)
  • If had a transplant and taking cyclosporin Erythromycin
50
Q

Which drugs should you reduce dose of in CKD pts?

A

Aciclovir, Amoxicillin, Ampicillinm Cefalexin, Erythromycin

51
Q

What is acute kidney injury?

A

Medical emergency, potassium rises to a dangerous level that leads to cardiac arrythmias and cardiac arrest. May be seen in hypovolaemia (if bled a lot)

52
Q

How can potassium level be lowered in acute kidney injury?

A
  • Calcium resonium (rectal)

- Glucose and insulin IV infusion - take potassium out of bloodstream

Human Diseases Yr4 (10 decks)

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