Fichas
CKD + ESRD
Fichas del conjunto (78)
- 1what is the definition of CKD?impaired renal fxn for >3 months (abnormal structure/fxn)
OR
GFR<60ml/min for >3 months +/- evidence of kidney damage - 2how is renal impairment classified in CKD?by GFR
1 - >90 - normal/increased with other evidence of renal damage(?)
2 - 60-89 - + other evidence renal damage
3a - 45-59 and 3b - 30-44 - +/- other evidence of renal damage
4 - 15-29 +/- other evidence renal damage
5 - <15 - established failure - 3what is "other evidence of renal damage"?proteinuria
haematuria
abnormal anatomy
systemic dz - 4what is the issue with using eGFR to grade renal disease?eGFR is only a screening test and can underestimate renal fxn esp in mild impairment
- 5when in CKD do symptoms appear?stage 4
- 6what is ESRF?stage 5 or
when RRT is needed - 7what causes CKD?diabetes - Type II>type I
glomerulonephritis (IgA nephropathy, SLE, vasculitis)
idiopathic - present with small shrunken kidneys
HTN/renovascular dz
pyelonephritis/ reflux nephropathy
adult polycystic kidney dz
chronic interstitial nephritis eg myeloma
alport's
fabry's - 8is screening useful in CKD and for whom should it be considered?yes, early intervention can slow progression
in:
DM, HTN, CVD, structural dz, recurrent UTI
multisystem eg SLE
fhx ESRF/ APKD - 9does everyone with CKD progress at the same rateno come may have little/none over many years - in some there is not a lot of benefit to labelling them with dz
- 10what symptoms might CKD patients report?uraemic - anorexia, vomiting, restless legs, fatigue, wkness, pruritis, bone pain
women - amenorrhea
men - impotence
oliguria, dyspnoea, ankle swelling - 11what signs may be seen on examining a pt with CKD?1st presentation - pallor, uraemic tinge (yellow) to the skin, purpura, excoriations, HTN, cardiomegaly, fluid overload, ballotable (polycystic) kidneys
untreated in extremis - severe uraemia + hyperkalaemia = arryhthmia, seizures, coma, encephalopathy - 12broadly, what tests to do in CKD?blood
urine
imaging
histology - 13bloods in CKD?hb - normo normo anaemia
ESR
U+E
glucose (DM)
low ca++, high Phosphate, low alk phos (renal osteodystrophy)
high PTH if stage 3 + - 14urine in CKD?dipstick
MC+S
albumin:creatinine ratio - 15imaging in CKD?USS- size, anatomy, corticomedullary differentiation (renal parenchymal dz eg DM, HTN)
small - CKD
enlarged - infiltrative dz eg myeloma, amyloid, APKD, DM
asymmetrical - MAG3 renogram - contribution of each kidney to overall fxn - 16histology in CKD?consider bx if rapidly progressing/ unclear cause + normal size kidney
- 17what are the three things you are looking for when examining pt w/ known CKD?cause - eg APKD, IHD, DM
current RRT +/- complications eg transplant/skin malignancy from immunosuppresion
previous RRT + complications eg AV fistula + parathyroidectomy scar - 18what peripheral signs may exist on examination of a patient w/ known CKD/ESRF?HTN
AV fistula
transplant signs - 19what to look at on an av fistula from RRT?thrill
bruit
recently needled? - 20what signs of previous transplant may be seen on a pt with CKD/ESRD?bruising from steroids
skin malignancy from immunosuppression
hockey-stick scar
palpable mass RIF - 21what may you see in the face on examining a pt w/ CKD/ESRD?pallor
yellow tinge of uraemia
gum hypertrophy (ciclosporin)
cushingoid appearance (steroids) - 22what may be seen in the neck in a pt w/ CKD/ESRD?current/previous tunneled line insertion (previous = small scar over IJV + larger scar in breast pocket area from exit site)
scar from parathyroidectomy - 23what may be seen in the abdomen in a pt w/ CKD/ESRD?PD catheter or sign of previous catheter - small scar below umbilicus+ small round scar to side of midline from exit site
ballotable kidneys
transplant signs - 24what other general signs might you look for in a pt with CKD/ESRD?signs of diabetic neuropathy, retinopathy
cardiovascular dz
peripheral vascular dz - 25what might cause a rapid decline in renal function more than expected?infection
dehydration
uncontrolled BP
metabolic disturbance eg high Ca
obstruction
nephrotoxins - 26why is falling GFR NB?INDEPENDENT RF for CVD which is the chief COD from renal failure
- 27what is the gold standard for calculating eGFR?insulin clearance because:
100% of filtered insulin is retained in the luminal fluid
BUT - requires the collection fo urine over several hours + constant IV insulin infusion - inconvenient. - 28list the ways GFR can be estimated?1) MDRD equation (serum creatinine, age, gender, race) - not validated for mild impairment, can be affected by variation in serum creatinine eg after protein rich meal
2)cockcroft gault equation - creatinine clearance - improves on MDRD as also accounts for weight BUTsmall amts of creatinine are reabsorbed in the distal tubule thus underestimating the GFR. Unreliable in those oedematous/obese
3) 24hr urine collection can estimate creatinine clearance by measuring excreted + compare w/ serum creatinine conc - accuracy poor.
4) insulin clearance - 29list some nephrotoxic drugscontrast - esp high osmolality
heavy metals - mercury, lead, arsenic
abx - aminoglycoside, amphotericin B, rifampin, vanc
antivirals - acyclovir, cidovir, foscarnet
chemotx - cisplatin, MTX, mitomycin C
NSAIDs - ibuprofen
ACEIs - rampiril, lisinopril
ARBs - losartan
immunosuppressant meds - cyclosporin, tacromilus - 30how to avoid contrast induced nephrotoxicity?lowest poss dose
hydrate pre and post
temporarily decrease other nephrotoxic drugs - 31when is CKD handled by nephrologist?stage 4/5
proteinuria ACR >70 (unless w/ DM already txed)
proteinuria + haematuria
rapid GFR decline - >5/yr/ >10 in 5yrs
poorly controlled BP despite 4 drugs at therapeutic doses
rare/genetic cause
renal artery stenosis - 32what are the four stages of management for CKD?investigation
limiting progression/complications
symptom control
preparation for RRT - 33what's involved in CKD investigation?ID + tx reversible causes eg obstruction, nephrotoxic drugs, deal w/ high Ca, stop smoking, manage CV risk, glucose control in DM
- 34what categories should be considered in limiting progression and complications in CKD?BP
Renal bone dz
CV mods
Diet - 35BP approach in CKD?target = 130/80, less if DM or ACR>70
if diabetic kidney dz treat even if BP normal w/ ACEI or ARB - 36approach for renal bone dz?we're talking renal osteodystrophy or adynamic bone dz
check PTH + tx if raised
phosphate rises in CKD which causes PTH to rise
restrict diet, give binders (calcichew) to reduce gut absorption
vit D analogues + Ca+ supplements - 37approach to CVD in CKD?stages 1+2 = risk from CVD is higher than risk from CKD
statins to pts w/ raised lipids
aspirin - 38diet in CKD?MDT - dietician
moderate protein
K restriction if hyperK
avoid high phosphate foods - 39list some high phosphate foods?milk
cheese
eggs - 40what does symptom control involve in CKD?anaemia
acidosis
oedema
restless legs/cramps - 41managing anaemia in CKD?replace iron/B12/folate if needed
consider recombinant human EPO - to increase Hb in iron/B12/folate deficient pt - if doesn't work think red cell aplasia (anti-EPO ab) - help from haematology
Hb aim - 10-12 - higher = risk thrombosis, HTN, MI - 42managing acidosis in CKD?sodium bicarb supplements if low serum bicarb
can improve sx + slow progression
caution in HTN as Na can increase - 43managing oedema in CKD?high dose loop diuretics eg furosemide
restrict fluid + Na - 44restless leg/cramp mangt in CKD?low ferritin worsens
clonazepam/gabapentin
quinine sulfate - 45what are the indications for renal bx?unexplained AKI/CKD
acute nephritic syndrome
unexplained proteinuria + haematuria
systemic dz w/ abnormal kidney fxn
suspect transplant rejection - 46what are the c/i to renal bx?abnormal clotting
HTN
single kidney except in transplant
CKD w/ small kidneys
uncooperative pt
horseshoe kidney
renal neoplasm - 47pre-renal bx care?check FBC, clotting, group + save
written informed consent
US - anatomy
stop anticoagulants (aspirin 1 wk, warfarin 2-3 days, LMWH 24hrs) - 48post renal bx care?bed rest
monitor pulse, BP ,urine
complication - bleeding usually in 8hrs but up to 72/ macroscopic haematuria
if uncomplicated, restart aspirin/warfarin next day - 49what complications can arise from bleeding in a renal bx?bleeding itself is because kidney is densely vascular and because of the propensity for bleeding seen in failure (uraemic coagulopathy) - usually bleeding is little and resolves itself, sometimes is brisk and needs transfusion or surgical angioembolisation.
haematoma/ haematuria/ clot in bladder - urinary retention - 50other complications of renal bx?infection
allergy
inaccessible kidneys
av fistula - 51how to prescribe in renal failure?modify dose according to GFR + drug renal excretion
renal drug handbook - 52when a pt doesn't want RRT..?must focus on conservative mangt and sx control
ie in very elderly or those with significant comorbidities RRT may not be acceptable - 53what is the best RRT?transplant - but not always successful and involves major surgery!
- 54what are the other kinds of RRT aside from transplant?haemodialysis
haemofiltration
peritoneal dialysis - 55what is HD?blood passes over semipermeable membrane AGAINST dialysis fluid - thus always meets a less conc solution and there is diffusion of small solutes down the conc gradient - does not clear large solutes as well
- 56what problems are associated with HD?disequilibration syndrome
hypotension
time consuming
access probs - AV fistula: thrombosis, stenosis, steal syndrome. Tunnelled venous access line: infection, blockage, recirculation of blood. - 57what is disequilibrium syndrome?CNS signs from cerebral oedema - focal neuro deficits, papilloedema, decreased consciousness
- 58what is haemofiltration?blood filters over HIGHLY permeable membrane - large + small solutes move
blood and dialysis fluid go in same direction
less haemodynamic instability as ultrafiltrate is replaced w/ same fluid volume
impractical long term as takes long time to clear compared to HD
used in critically ill - 59what is peritoneal dialysis?peritoneum is the semi permeable membrane
Tenchkoff cath into peritoneal cavity - fluid infused
solutes diffuse slowly - can speed up filtration by adding osmotic agents eg glucose to the fluid
easy, can be done at home, more freedom - 60what problems are associated with PD?peritonitis
exit site infection
loss of membrane fxn over time - 61what are the complications of dialysis?annual mortality 20% mostly from CVD
CVD - MI/CVA much more common (HTN + calcium/ phosphate dysregulation)
protein calorie malnutrition - in HD
renal bone dz- high turnover, ROD, osteitis fibrosa (from high PTH)
infection - uraemia = granulocyte dysfunction. Sepsis.
malignancy - more in dialysis pts - 62what to think about if stopping dialysis?8-20% dialysis deaths are due to withdrawal
but may be right thing if v old, or comorbidity eg psych/mobility - 63what are the absolute C/i to renal transplant?active infection
cancer <5yrs ago + not cured
severe comorbidities - 64what kinds of grafts exist for renal transplant?DCD - donor after cardiac death
DBD - donor after brainstem death
LD - living donor - 65DCD considerations in transplant?high risk delayed graft fxn from long warm ischaemic time
- 66considerations in DBD for transplant?remain on Cardioresp support for retrieval
reduced chance of delayed graft fxn - 67considerations for LD when renal transplant?better outcomes - planned surgery, minimal ischaemic time
donor - need psych assessment + ensure understand all risks - 68how is immunosuppression carried out for kidney transplant?1) induction - IL-2R mab - basiliximab but many centres are using alemtuzumab now (campath)
2) maintenance - 3x therapy of calcineurin inhibitor (tacromilus, ciclosporin), antimetabolite (aza/ mycophenolate), prednisolone - 69why alemtuzumab (campath) over basiliximab?broad immunosuppression, steroid free mainetenance which is especially useful in pt w/ DM
- 70what complications of renal transplant exist?surgical
delayed graft fxn
rejection
drug toxicity
infection
malignancy
CVD - 71surgical complications renal transplant?bleed
thrombosis
infection
urinary leak
lymphocoele
hernia - 72delayed graft function in renal transplant?40%
esp DCD
from ATN in graft due to ischaemia-reperfusion injury - 73rejection in renal transplant?acute - humoral (ab mediated) or cellular (more common) - tx for either = high dose methylprednisolone + increased IS. ab mediated may need plasma exchange
chronic - called "chronic allograft nephropathy" - chronic low grade ab response + vascular changes + CNI effects - does not respond to tx but can slow by switching CNI to siromilus - 74drug toxicity in renal transplant?neuro - tremor/confusion (CNIs)
new onset DM after transplant (NODAT)
gum hypertrophy + hirsutism (ciclosporin)
agranulocytosis + hepatitis (antimetabolites) - 75infection in renal transplant?increased risk for all
opportunistic + viral from poor t cell response eg HSV, candida, CMV - 76malignancy in renal transplant?5x increased risk w/ IS esp skin + virus associated
cervical smears regularly - 77CVD in renal transplantfrom drug effects - leading COD in transplant pts
HTN - from donor vasc dz in graft + IS - 78px in renal transplant?improving
high 1yr
10yr 60 (DCD)-99% (LD)
Información
- Descripción
- University nephrology Fichas sobre CKD + ESRD, creado por roatf1 el 27/10/2014.
- Creado por
- roatf1 · oct 2014
- Actualizado
- 3 feb 2018
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