Renal2

Question 1

When does oedema occur in CKD

Answer 1

Usually in severe CKD

And it starts as pedal

Often ankle oedema doesnt need treatment in severe CKD as it is not necessarily fluid overload

Question 2

Management of ankle oedema in CKD

Answer 2

1. Check blood pressure and Respiratory rate
2. If no other signs of fluid overload - mild ankle odema can be managed with a) raise legs b) stockings c) moderate salt restriction
3. ONLY use diuretics if there’s evidence of fluid overload on clinical assessment

Question 3

Management of pulmonary oedema in CKD

Answer 3

• Usually warrants diuretics
• Significant will require hospital care
• Diuretic resistance occurs in later stages of CKD
• Refractory oedema in late CKD can be an indication to commence dialysis

Question 4

IS BNP useful in CKD with oedema

Answer 4

unreliable

Question 5

Potential causes of oedema in patients with CKD

Answer 5

1. CKD - reduced water excretion/urine output
2. Nephrotic syndrom
3. Meds (amlodipine, nifedipine, steroids)
4. Sodium retentiin or excess intake
5. CCF
6. Liver disease and low alb
7. lymphoedema
8. Vascular causes (DVT)
9. Dependent oedema

Question 6

How common is pruritis in CKD? HOw is it managed?

Answer 6

70% in stage 4 and 5 (EGFR under 30)

Causes - calcium phosphate imbalance; inadequate dialysis; overactive parathyroid; increased magnesium and vitamin A, nerve changes in skin

Management -

1. Check for other causes (skin disease, scabies, inadequate dialysis, check ca/phos)
2. Evening PRIMROSE OIL
3. Skin EMMOLIENTS
4. Topical CAPSACIAN
5. oral gabapentin if there’s also restless legs
6. Derm referral for UV therapy

Question 7

How common is restless legs in CKD?

Answer 7

8 in 10 people with ESKD (less than 15) have restless legs or periodic limb movements in sleep (PLMS)

Managment

1. Check iron - replace if LOW
2. Home therapies - massage, relaxation, exercise, warm baths, warm compresses
3. Low dose dopaminergic agent or dopamine agonist
4. Benzodiazapines
5. PRAMIPEXOLE

Question 8

CKD and Gout? Whats the relationship?

Answer 8

Increased uric acid

can cause:

1. renal stones
2. Tubulointerstitial nephritis TIN
3. AS CKD progresses - will increase uric acid leading to GOUT

Managmeent - NSAID contraindicated if less than 30EGFR and best avoided

colchicine dose adjustment needed - avoid

Use prednisolone instead UNLESS there’s an infection

Question 9

What pain relief is acceptable in CKD? Which are contraindicated? Whats better short term vs long term

Answer 9

Paracetamol - analgesia of choice. Can also use liquid form.

CANNOT give codeine, NSAIDs or morphine due to toxicity in CKD.

Can give dose reduced oxycodone or tramadol.

Long term - fentanyl, buprenorphine (norspan) patches OR methadone (hard to titrate but safe).

Short term: Hydromorphone 0.5mg - 1mg Subcutaneously QID (this 5 to 7 times more potent than morphine)

Question 10

Neuropathic pain in CKD

Answer 10

low dose gabapentin (high dose is toxic)

Question 11

What is the triple whammy

Answer 11

ACE or ARB

+

Diuretic

+
any NSAID

Question 12

What are non modifiable RF’s of Acute kidney Injury

Answer 12

1. CKD
2. DM
3. Cancer
4. Anaemia
5. Heart/Lung/liver disease
6. AGE
7. Female

Question 13

What are modifiable RFs for AKI

Answer 13

1. Hypovolaemia (from sepsis/illness/trauma etc)
2. Drugs (Eg Triple whammy)
3. Radiocontrast agents
4. Poisonous animal (spiders snakes)
5. Heatwaves

Question 14

How is AKI diagnosied

Answer 14

Cr - 1.5 times baseline within seven days.

OR

CR - greater than or equal to 26.5 micromol/L within 48 hours

OR

Significant reduction in urine output compared with normal

Question 15

How can AKI be managed

Answer 15

• Early specialist review
• Medication review
• Fluid review
• Remove risks for AKI early

Question 16

After an episode of AKI what follow up?

Answer 16

1. Needs ANNUAL kidney check for the next 3 years
2. Patient education and risk reduction
3. Note in practice notes as AKI (resolved)

Question 17

Which meds should be withheld during acute illness (GI illness or dehydration) in patients with CKD?

Answer 17

Sulphonylureas (reduced clearance)

Ace

Diuretics

Metformin (reduced clearance)

Arb

NSAID

Sglt2 inhibitors

(note - aside from MetSulph the others cause increased risk of decline in renal function (action)

Question 18

What is considered Hyperkalaemia in CKD?

Answer 18

In CKD urinary excretion of potassium is impaired

Potassium greater than or equal to 6

If greater than 6.5 - send to Emergency Dept

If 6 or more:

Avoid salt subs which may high in K+

Resonium A

Low Potassium diet (refer to dietician)

Correct metabolic acidosis (target serum HCO3 greater than 22)

Potassium wasting diuretics (eg thiazide)

CEASE ACE/ARB/Spironolactone if Potassium persistently over 6 despite the above therapies

Question 19

Which simple kidney cysts need review or further Ix?

Answer 19

Multiple cyts

Bilateral Multiple

Phx of cancer

symptoms from cyst (infection, haematuria, discomfort)

Cyst with complex internal structure or solid components

Inability to distinguish cysts from obstruction

Question 20

What are the features of simple cysts

Answer 20

1. Very common
2. Do not cause kidney failure
3. Not inherited
4. May be associated with background kidney failure
5. Can occur with advancing age
6. Usually ASYMPTOMATIC

Question 21

What is the most common inherited kidney disorder

Answer 21

Polycystic Kidney Disease

Question 22

Can PKD cause CKD

Answer 22

yes. Polycystic kidney is a common cause of CKD.

Question 23

When would you consider a diagnosis of PKD?

Answer 23

AGE 15-39 - 3 cysts in TOTAL on u/s

40 - 59 - At least 2 cysts on each kidney

Over 60 - At least 4 cysts on each kidney

Question 24

Whats the clinical management of Autosomal Dominant Polycystic Kidney disease

Answer 24

1. Assess if high risk for ESKD
2. Reduce - cyst growth - Prevent - decline in eGFR and hypertension
3. Evaluate for other kidney complications
4. Discuss other problems

The medication TOLVAPTAN - for early CKD (stage 2 or 3) with rapidly progressing ADPKD.