Renal failure & its management symposium

Question 1

What stimuli contribute to causing the following?

• Glomerulosclerosis
• Interstitial Scarring
• Tubular atrophy

Answer 1

• Diabetes
• Hyperfiltration
• Vascular disease
• Hypertension

Question 2

What is the classification of Chronic Kidney Disease

Answer 2

Question 3

How should proteinuria be measured?

Answer 3

• Spot urine sample for protein: creatinine or albumin: creatinine ratio
• all patient with CKD stage 3+ should have proteinuria measured at least once

Question 4

What is normal and abnormal Proteinuria in non-diabetics?

Answer 4

Normal

• ACR <_ 30 mg/mmol
• PCR <_ 50mg/mmol

Abnormal

• ACR > 30 mg/mmol
• PCR > 50mg/mmol

Question 5

What is normal and abnormal Albuuminuria in diabetics (men and women)?

Answer 5

Question 6

What is the target BP and treatment in CKD in patients with PCR <50 mg/mmol?

Answer 6

• BP target:140/90
• NICE 120-139/<90
• ACE inhibitors optional

Question 7

What is the target BP and treatment in CKD in patients with PCR between 50-99 mg/mmol?

Answer 7

• BP target 140/90
• NICE 120-139/<90
• Use ACE inhibitors as the first line
• Refer only if haematuria also present, or progressive GFR decline

Question 8

What is the target BP and treatment in CKD in patients with PCR >_ 100 mg/mmol?

Answer 8

• BP target <130/80
• NICE 120-129/<80
• Use ACE inhibitors as first line
• Refer

Question 9

What is staging/ classification of Acute Kidney Injury?

Answer 9

Question 10

What is ESRF?

Answer 10

End-stage Renal Failure

• mortality increase with age and in incidents of diabetes in younger patients (around 45)

Question 11

What assessment can be made for AKI?

• using an acronym

Answer 11

• Sepsis: identity/screen and teat
• Toxins: drugs/ iv contrast
• Optomis BP/volume statute: withhold diuretics/ antihypertensive?
• Prevent harm: identify other causes i.e obstruction, review medication and fluid does and prescription

Question 12

What are the 3 main categories/ types of AKI?

Answer 12

• Pre-renal AKI
• Intrinsic AKI
• Post-renal AKI

Question 13

What is the cause of Pre-renal AKI?

Answer 13

• Sepsis
• TOxins: IV contrast
• Hypotension: V&D, Diuretics, Haemorrhage, burns, medication ACEi, cardiac failure
• Hepatorenal syndrome: linked with portal hypertension and liver cirrhosis
• Renal artery stenosis

Question 14

What is the cause of Post-renal AKI?

Answer 14

• Kidney stones
• Prostatic hypertrophy (enlarged prostate causes occlusion of the urethra)
• Tumours
• Retroperitoneal fibrosis (Ormand’s disease): excess fibrous tissue develops in the space behind your stomach and intestine- the retroperitoneal area

Question 15

What is the cause of Intrinsic AKI?

Answer 15

• Acute tubular injury: prolonge pre-renal, nephrotoxins
• Tubulointerstitial injury
• Glomerulonephritis
• Myeloma
• Lupus Nephritis (an autoimmune disease)
• Vasculitis: ANCA ( antineutrophil cytoplasmic antibody-associated) autoimmune disease
• Haemolytic uraemic syndrome (HUS): the destruction of platelets, also affects blood vessels and RBC
• TTP: Thrombotic Thrombocytopenic Purpura- blood clots found in small blood vessels, a severe decrease in platelets, and destruction of RBC

Question 16

What symptoms would indicate urgent renal replacement?

Answer 16

• Uncontrollable fluid overload
• Uncontrollable, severe metabolic acidosis
• Uncontrollable hyperkalaemia
• Uraemic pericarditis/encephalopathy

(poisoning ethylene glycol, lithium NSAIDs)

Question 17

What drug would cause issues at stage 3A CKD?

• eGFR 45-59

Answer 17

• Metformin: used in diabetes
• increased lactate production
• results in lactic acidosis
• most other drugs would be fine to metabolism at this level

Question 18

What needs to be considered in drug distribution when administering drugs?

Answer 18

• whether the drug needs to be protein-bound e.g warfarin and phenytoin
• both bound to albumin
• if albumin level is low as they may be in renal failure, the free phenytoin or warfarin is increased which isn’t effective

Question 19

How is Vitamin D absorbed?

Answer 19

Question 20

What needs to be assessed for kidney patients?

Answer 20

• the trend of the BLood results
• type of kidney disease and the stage
• type of treatment the patients is on: dialysis transplant, conservative management
• Fluid balance: weight, urine output, observation
• Malnutrition risk (MUST
• other heat conditions: diabetes, CVD
• the medications the patients are on

Question 21

How should fluid be balanced in renal patients?

Answer 21

• No kidney function 500-750mls per day
• Impaired kidney function- generally encourage to drink
• Transplant- Generally drink lots post-transplant, to make sure transplant is well perfused (can be difficult for previous dialysis patients)
• Haemodialysis- 500mls plus the amount of urine passed over 24-hour
• Peritoneal dialysis- 750mls plus 24-hour urine

Question 22

What differentials may impact a patients fluid balance?

Answer 22

• poor diabetic control can make a patient more thirsty
• decreased urine output (rapid weight gain due to water retention)
• the patient is unaware of fluid restriction

Question 23

What is the target potassium levels for dialysis and low clearance levels?

and what is the importance of K

Answer 23

• Dialysis: 4-6mmol/L
• Low clearnace: 3.2-5.5mmol/L
• muscle and cardiac function

Question 24

What are some other differential causes for high potassium levels?

Answer 24

• Acidosis
• Inadequate dialysis dose
• Medications (especially ACE inhibitors), some diuretics as well
• Poor diabetic control
• Constipation
• Blood transfusions
• Haemolysed samples
• Catabolism/sepsis/ infection

Question 25

What are the targets for phosphate for dialysis and low clearance patients? what is the treatment for high and low levels?

Answer 25

* 1.1 – 1.7 mmol/L dialysis. * 0.9 – 1.5 mmol/L low clearance high phosphate- Low phosphate diet plus phosphate binders (these can be difficult to adhere to check up on patient)/ alfacalcidol (PTH) low phosphate - Low PO4: Assess malnutrition risk, especially in renal patients

Question 26

What are the target protein levels?

Answer 26

* Targets: 0.8g/ kg ideal body weight low clearance and transplant patients * 1-1.2g/ kg ideal body weight dialysis patients

Question 27

What nutrient advice is useful for end-stage kidney disease?

Answer 27

- avoid fat-soluble vitamins, e.g A, D E and K - routine supplementation of water-soluble vitamins for all dialysis patients

Question 28

How can kidney function be preserved?

Answer 28

- Avoiding excess protein and salt - Optimising blood glucose - Optimising blood pressure - Weight management - Optimising nutrition - Keeping active

Question 29

What needs to be considered for managing nutrition for multiple health conditions? - what conditions need nutrition to be managed?

Answer 29

**• Special diet burnout** * Diabetes * Malnutrition * Obesity * Gastro complications *_• Depression_*

Question 30

What are the 3 categories of renal patients?

Answer 30

- Stable poor renal patients - Renal function deteriorating - Renal patient deteriorating, chosen conservative management