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Long case clinical skills > Renal long case > Flashcards

Renal long case Flashcards

1
Q

Differentials for CKD

A

T2DM

HTN

Reflux nephropathy

SLE/SScl

Polycystic kidneys

Glomerulonephritis

Severe AKI

Interstitial/analgesic nephropathy

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2
Q

Risk factors for CKD

A
  • NSAIDs, radiocontrast, infection, ACEI/ARB, dehydration, anaemia
  • Family history, vesicouroteric reflux/congenital urogenital abnormalities,

T2DM

HTN

vasculitis

renal calculi

gout

polycystic kidneys

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3
Q

History for CKD

A

nocturia, lethargy, loss of appetite, pruritis

limb swelling, oedema; haematuria, rashes, haemoptysis, joint issues

nephrotic syndrome, nephritic syndrome

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4
Q

Investigation for CKD

A
  • For diagnosis – MSU, RT USS, CT-IVP; renal biopsy
  • ANA complement,cryoglobulins, immunoelectrophoresis ANCA, Hep B/C, HIV,
  • Ultrasound kidneys for size and post renal obstruction
  • blood tests – eGFR, creatinine, urea; calcium/phosphate/magnesium; anaemia
  • HTN management
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5
Q

Management CKD - overall

A

Fluid overload/dialysis Dialysis planning/Transplant work up Anaemia Potassium/acidosis Metabolic bone disease Ureamic bleeding Restless legs Sexual dysfunction Cardiovascular risk factor control

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6
Q

Management CKD - dialysis planning

A
  • Contraindications to Continuous Ambulatory PD or Automated PD – abdominal surgery, poor dexterity, poor social support, previous peritonitis, cognitive impairment)
  • AV fistula creation
  • Tencholff catheter creation
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7
Q

Management CKD - metabolic bone disease

A
  • Calcium levels, phosphate levels, PTH level
  • Phosphate binders with meals, low phosphate diet
  • Tertiary hyperparathyroidism

– parathroidectomy +/- autologous parathyroid transplant

  • Vitamin D levels and calcitriol supplementation
  • Osteoporosis, previous fractures, DEXA scan, bisphosphonate therapy
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8
Q

Management CKD - fluid overload

A
  • Making urine, dry weight, fluid restriction, diuretic therapy, salt restriction, dialysis days, access via car/taxi, travel; daily weights
  • PD – bag changes, sterile technique, assistance from carer, daily weights, weight gain ‘action plan’, home dialysis nursing service
  • Continuous ambulatory/ambulatory
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9
Q

A/CKD complication - differential

A

HTN, UTI, urinary obstruction, dehydration, cardiac failure; drugs

– contrast, NSAIDS, hypothyroidism, hypoadrenalism

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10
Q

Haemofiltration criteria

A

fluid overload, potassium, acidosis, toxins, pericarditis

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11
Q

Treatment for graft rejection

A

IV methylprednisolone, IV biologics (monoclonal Abs), plasma exchange Biopsy

Differentials – CMV, BK, systemic infection

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12
Q

Complications

A

Drug related

Opportunistic

infections

Neoplasm

Recurrence of glomerulonephritis

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13
Q

Cyclosporin complications

A

tremor

gout

hirsuitism

deranged LFTs

HTN

hyperkalaemia

low magnesium

gingival hypertrophy

renal impairment

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14
Q

Tacrolimus complications

A

tremor

T2DM

HTN

dyslipidaemia

squamous cell carcinomas

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15
Q

Prednisolone complications

A
  • Osteoporosis, avascular necrosis of hip
  • T2DM, HTN, dyslipidaemia
  • Dysmorphic cushingoid features
  • High doses - Electrolytes – potassium, proximal myopathy, mania, PJP/opportunistic infections
  • Post op – reduced wound healing
  • Cataracts
  • Addisonism
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16
Q

Common opportunistic infections

A

BK

Cytomegalovirus

Pneumocystic jiroveci

Toxoplasma

Nocardia

Aspergillus

17
Q

Management/control in CKD

A
  1. Surveillance of renal function, anaemia, phosphate, calcium urea
  2. Surveillance of DEXA/osteoporosis, weight bearing exercises, blood pressure, dyslipidaemia, LFTs and FBE
  3. Access to dialysis nurses, specialists, follow up with appointments
  4. Daily weights, fluid restriction, use of PD equipment, low salt, phosphate potassium diets
  5. Dietician input Avoidance of high risk activities predispose to infection, PJP and viral prophylaxis
  6. Avoidance of smoking and alcohol
  7. Up to date with childhood vaccinations, influenza and pneumococcus
18
Q

History for chronic kidney disease

A

Cause of CKD

Uraemic symptoms - fatigue, anorexia, polyuria, nocturia, sleep disturbance, decreased appetite, nausea, vomiting, itch

Uraemic neuro complications - peripheral neuropathy, restless legs, pain asterixis, seizures, bone pain

Prior cardiac rhythm disturbances APO

Dialysis - commenced on dialysis, prior modalities, complications - peritonitis, dysequilibrium syndrome; fistula formation and complications

Producing urine

IHD risk factors and prior MI

Low potassium and phosphate diet

Fluid intake

Sexual dysfunction, menstrual disturbance

19
Q

Management of CKD

A

Diet - reduce protein intake 1g/kg, sodium to 2g/day, potassium to 2g/day

Control BP - target 120/75, ACE/ARB

Fluid restriction and diuretics in dialysis patients

Anaemia of chronic disease - EPO when haematocrit falls below 30%; requires iron replacement at 3x normal Fe levels; Fe, B12 and folate levels regularly, may contribute to HTN

Renal osteodystrophy -Low phosphate diet and phosphate binders, 1,25OH Vit D supplementation, parathyroid removal surgery

Acidosis - oral bicarbonate therapy

Cardiovascular status - Cholesterol level, BSL, HbA1c, TTE, stress tests etc.

20
Q

Spectrum of renal osteodystrophy

A

Hyperparathyroid disease - bone resorption and cyst disease, pepperpot skull

Osteoporosis

Osteomalacia

Osteosclerosis (secondary to hyperparathyroidism)

Adynamic bone disease - bone formation and resorption is impaired

21
Q

Complications of chronic renal failure

A

Platelet dysfunction

Pruritis, pigmentation, calciphylaxis

Gastrointestinal complications - Diarrhoea, PUD, pancreatitis, constipation

Endocrinological - amenorrhoea, erectile dysfunction, infertility

Neurological complications - peripheral neuropathy, carpal tunnel syndrome, confusion, coma, seizures

Cardiovascular disorders - pericarditis, hypertension, peripheral vascular disease, CCF, myocardial fibrosis

Gout

T2DM

Pancreatitis

Renal osteodystrophy

22
Q

Diagnostic criteria for Rheumatoid arthritis

A

Inflammatory arthritis involving three or more joints

Positive rheumatoid factor and/or ACPA

Duration greater than 6 weeks

Raised CRP and ESR

Exclusion of SLE, polyarticular gout, viral polyarthritis, seronegative arthritis

Long case clinical skills (12 decks)

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