Renal Medicine Flashcards by Charley Frew

What are the common causes of Pre-Renal AKI?

Sepsis
Hypovolaemic Shock
CCF (Congestive Cardiac Failure)
Drug Induced (NSAIDs, ACEi/ARBs)
Diabetes

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What are the common causes of Intrinsic AKI?

Vasculitis
Acute Tubular Necrosis
CKD
Reaction to Iodine Contrast

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What are the common causes of Post-Renal AKI?

BPH
Tumour
Bilateral Calculi
Urethral Stricture
Retro-Peritoneal Fibrosis

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How do you investigate an AKI (high creatinine)?

Urinalysis
U+Es
Measure Input/Output
Measure eGFR
Measure Lactate and Blood Gases
Measure BP
USS KUB

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What is the treatment for AKI?

Pre-Renal:
Fluids
Take away nephrotoxic agent

Intrinsic:
Renal Replacement Therapy

Post-Renal:
Refer to urologist to remove obstruction
Nephrostomy in meantime?

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What is meant by the term dehydration?

Your bodys fluid output is larger then it’s input

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What is meant by intravascular volume?

The volume of fluid in the body’s circulatory system. If this depletes then you could go into shock. Too high and you will have volume overload

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How do you carry out a fluid assessment on a patient?

Look around bed for fluids or fluid chart

Hands:
Pallor - hypo
Temp - cold = hypo
Capillary Refill Time (+2secs = hypo)

Pulse (rate + rhythm)
BP

JVP (raised = hyper)

Eyes
(Sunken or conjunctival pallor = hypo)

Mouth
(dry mucous membranes = hypo)

Chest
RR (high = pulm oedema secondary to hyper)
Listen to chest (fine crackles of pulm oedema)
Heart sounds (Gallop rhythm/3rd beat = hyper)

Abdo - Ascites

Sacral & Ankle oedema

Check urine output

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How does ADH (Anti-Diuretic Hormone) regulate fluid balance?

Synthesised in supraoptic nucleus
Released by posterior pituitary

ADH binds to V2 receptors at collecting duct
Causes H2O to flow out of CD to blood
So less urine is produced
Which raises BP

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What fluids would you give to a dehydrated patient with a BP of 95/60 & HR of 106?

Not hypotensive

0.18% Saline + Dextrose (stays intracellular)

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What are the requirements for maintenance IV fluids?

H20 30ml/kg/day
Na 1-2ml/kg/day
K 1ml/kg/day
Cl 1ml/kg/day

Glucose 50-100g/day

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What are the stages of CKD?

eGFR:
1- 90+
2 - 60-89
3a - 45-59
3b - 30-44
4 - 15-29
5 - <5

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What other investigations should be carried out to clarify CKD stage?

Albuminuria (uACR ratio - urinary Albumin Creatinine Ratio)

A1 - <30mg/g
A2 - 30 - 290 mg/g
A3 - 300+mg/g

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What are the most common causes of CKD?

Diabetes
HTN
Glomerulonephritis
Renovascular Disease
Polycystic Kidney Disease
Pyelonephritis

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What clinical examinations would you like to seek with a patient with CKD?

Urine Dip (proteinuria or haematuria)
U&Es
BP Monitoring (HTN cause + BP high in nephritic)
Blood Glucose

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What tests/investigations could you do confirm the cause of CKD?

Urine dip - nephrotic or nephritic
Kidney USS - Polycystic Kidney Disease
Blood Glucose
Biopsy for nephritic syndromes

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What medication can CKD sufferers not be on?

NSAIDs
PPIs
Statins (adjusted dose)
Abx (some)
Diabetic Medicsations (adjusted)

Contrast Dye (CT, MRI)

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How does peritoneal dialysis work?

You put fluid into the peritoneum through a catheter.
Solutes move from the patient’s blood across the peritoneal membrane down a conc gradient into the dialysate fluid (high osmotic gradient in fluid draws water in)

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What are the different types of Peritoneal Dialysis?

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Automated PD:
Automated cycler machine performs dialysis at night.

Continuous Ambulatory PD:
4-5 dialysis exchanges per day

What are the advantages and disadvantages of peritoneal dialysis?

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+ Quality of life
+ Can be done at home
+ Give patients some level of responsibility

Patients have to do it themselves
Unsuitable in patients with stoma/surgeries

What are the complications of peritoneal dialysis?

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PD Peritonitis
Hernia
Leaking
Malposition

How does haemodialysis work?

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Tubing from dialysis placed in patients veins
Blood drawn out placed into dialyser, solutes removed from blood in machine and then put back into patient

What are the advantages and disadvantages of haemodialysis?

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+ Very efficient
+ Support from staff and sterile

Dialysis access needs to be secured
Have to be at hospital
Can’t do anything while hooked up to the machine

What are the complications of haemodialysis?

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Infection
Bacteraemia
Haemodynamic instability
Risk of bleeding
Anaemia
Central line infections

What are the advantages and disadvantages of renal transplant?

+ Near normal lifestyle + Better mortality/morbidity - Criteria to meet operation - Compliance with lifelong meds - Risk of rejection - Risk of malignancies over time - Long waiting times - HIGH RISK OF INFECTION (immunosuppression)

How do you manage CKD patients with mineral bone disease?

Synthetic calcitriol to reduce PTH levels Calcium + Vit D supplements Calcimimetics to lower PTH levels Phosphate binders (so more excreted) Diet with reduced phosphates Parathyroidectomy

How do you manage end stage renal failure patients with anaemia?

EPO Injections B12, folate, iron, ferritin supplemetns

What are the pros and cons of live vs deceased donors in organ transplants?

Living donor transplant has longer survival time Transplant time is usually shorter too Person donating the organ also has to live with only one kidney. You can get 2 kidneys from deceased donors, not one. [Living related donor best form of course as less chance of rejection]

What are some contraindications for kidney transplantation?

Active malignancy Severe heart or lung disease Renal disease Substance abuse Psychiatric illness

What drugs are given for immunosuppression in maintenance therapy in transplants?

Steriods (prednisolone) Calcineurin Inhibitors (tacrolimus, cyclosporine) Antimetabolites (azathioprine, mycophenolate) T cell Regulation (belatacept, belimunab) Rapamycin Inhibitors (sirolimus)

What drugs are given for immunosuppression in induction therapy in transplants?

Methylprednisolone Basiliximab + Thymoglobulin Rituximab (less used)

What is the difference between induction and maintenance therapy?

Induction - at the moment of transplantation (more potent) Maintenance - lifelong meds to prevent rejection in the future

What is the long term care/monitoring needed for renal transplant patients?

Monitor GFR Monitor proteinuria Monitor Ca, Phosphate, PTH, Glucose Vaccinations (not live) Screen for infections Monitor CVD (high mortality w/ transplant) Monitor bone and mineral disease CONTRACEPTION IN 1ST YEAR AT LEAST

What can be defined as an AKI?

1.5 x baseline creatinine +26 Umols/L creatinine within 48hrs

What can be considered as a stage 3 AKI? (x3)

x3 baseline creatinine Needing RRT +354 Umol/L creatinine within 48hrs

How can we manage post-renal AKI with full bladder or hydronephrosis/ureter?

Suprapubic catheter or nephrostomy Monitor fluid input/output + K levels Can become hypokalaemia or hypovolaemic

What cell will be raised in the serum and urine in interstitial nephritis?

Eisonophill

What is the pneumonic for general management of AKI?

Perfusion: Fluid Status Withold BP lowering meds Vasopressors or fluids needed? Underlying Cause: SEPSIS 6 Catheterise if obstruction Monitoring: Daily U+Es Volume Status Prevent + Treat Complications: Hyperkalaemia Acidosis Pulmonary Oedema

How do we know if a patient is hypovolaemic?

Low BP High HR Reduced Skin turgor Dry mouth/skin High Urea + normal creatinine + ^RBC Postural hypotension

What are some risk factors for AKI?

Contrast for imaging (ensure hydrated before use) Nephrotoxic agents On Diuretics already

How can we distinguish between AKI or CKD?

CKD - Anaemia more likely USS Kidney changes in CKD CKD: Low Ca, ^phosphate, ^PTH AKI - acute illness/presentation

How low does the Mean Arterial Pressure have to drop to increase the risk of ATN?

Below 70

How do we treat suspected hypovoolaemia in HF?

Cautious fluids (start small and work up) Constant monitoring

How can Polycystic Kidney Disease present acutely?

Sub-arachnoid haemorrhage

What type of cysts affect blood pressure and what don't?

Polycystic Kidneys can affect BP Normal renal cysts definitely don't

Why does nephrotic syndrome increase VTE risk?

Losing protein, trombone and clotting factors in urine. Blood becomes more coagulable

Renal Medicine Flashcards

(47 cards)