Renal

Question 1

What are the 2 main types of dialysis?

Answer 1

Haemodialysis

Peritoneal dialysis

Question 2

What is required for haemodialysis?

Answer 2

• Dialysis machine (patient’s blood is pumped OUTSIDE the body and through this machine)
• Vascular access is required via an AV fistula (longterm), or a temporary CVC

Question 3

What happens inside a haemodialysis machine (broadly)?

Answer 3

Blood flows through tiny semi-permeable tubes surrounded by a dialysis solution (dialysate)
Filtration occurs via osmosis and diffusion - dialysis fluid contains solutes at a similar level to the level they would be in a healthy patient’s blood
Can add bicarbonate (to combat acidosis), EPO and drugs if needed
Heparin always added

Question 4

How often should haemodialysis be performed?

Answer 4

4 hour treatment 3 times per week

Question 5

What are the 3 main possible complications of dialysis

Answer 5

• Blood infection (more common in peritoneal dialysis)
• Thrombosis
• Internal bleeding (due to added heparin)

Question 6

What is peritoneal dialysis?

Answer 6

Dialysis fluid is introduced into the patient’s abdominal cavity for several hours, and the peritoneum serves as the natural filter
Can be done automatically at night during sleep

Question 7

Recall some pros of peritoneal dilaysis

Answer 7

• Offers more flexibility (can be done overnight)
• Is better tolerated by patients
• Less expensive

Question 8

What is a tesio line?

Answer 8

• Tunneled dual lumen central line
• Used as a ‘bridge’ before an AV fistula can be put in
• One lumen enters the right atrium, the other
  sits outside the RA in the vena cava
• Both lumens exit the body (with a central line, only 1 lumen enters the skin)

Question 9

Why is a normal vein unsuitable for haemodialysis, and why is an AV fistula used?

Answer 9

Normal vein would easily collapse/ thrombose with recurrent venepuncture
Vein in an AV fistula hypertrophies in response to turbulent flow of blood from artery and so can withstand repeated venepuncture

Question 10

Recall some contra-indications to renal biopsy in acute renal failure

Answer 10

• Obvious pre or post renal cause (these are contra-indications)
• Significant coagulopathy
• Infection at the site

Question 11

What group of diseases is the most common cause of nephritic syndrome?

Answer 11

Proliferative glomerulonephritis

Question 12

Recall 5 causes of the nephrotic syndrome

Answer 12

Amyloidosis 
Diabetes
Focal segmental glomerulosclerosis 
Membranous glomerulonephritis 
Minimal change disease

Question 13

What are the most common causes of AKI?

Answer 13

Remember STOP:

• Sepsis/dehydration
• Toxins (NSAIDs, nephrotoxic drugs),
• Obstruction in the urinary tract
• Parenchymal kidney disease

Question 14

What are the most common causes of CKD?

Answer 14

Diabetic nephropathy

Hypertensive nephropathy

Question 15

What are the primary functions of the kidney?

Answer 15

Balance:

• Water
• Electrolyte
• Acid-base

Endocrine:

• erythropoietin
• vit D activation
• renin-angiotensin system
• BP control

Excretion:

• Waste
• Metabolites

Question 16

What symptoms might you expect from someone with CKD?

Answer 16

Fluid overload (pedal oedema, pleural effusion, ascites, tiredness)

Anaemia (SOB, tiredness, LoC, headcaches)

Hyperkalaemia (palpitations, cardiac arrest, asymptomatic)

Uremia (pruritis, confusion, pericarditis, encephalopathy)

Acidosis (nausea, vomiting,
tiredness)

Increased drug action (e.g. opioid side effects)

Reduced urine output

Question 17

What diet should be followed in patients with very low creatinine clearance?

Answer 17

Low phosphate
(eg. avoid chocolate, shellfish, nuts)

Low potassium (avoiding chocolate, bananas etc)

Fluid restricted (avoiding alcohol, avoid too much tea/coffee)

Low salt (avoiding processed foods)

Can take phosphate binders if diet restriction alone doesn’t succeed

Question 18

Recall a mnemonic that can be used to remember the most common indications for emergency dialysis

Answer 18

A – acidosis
E – electrolyte imbalance (K+ of 6.5+ and refractory to
medical management)
I – intoxication (certain drugs require dialysis to
clear the blood)
O – overload of fluid (refractory to diuretic treatment)
U – uraemic encephalopathy & pericarditis

BLAST mnemonic for drugs that can be dialysed out - 
Barbiturates
Lithium
Alcohol
Salicylates
Theophylline

Question 19

What can be used as an alternative to calcium gluconate in hyperkalaemia as a cardioprotective infusion?

Answer 19

Calcium chloride

Question 20

How might a chest x ray appear in Goodpasture’s syndrome?

Answer 20

Bilateral widespread airspace opacities

Question 21

Which diagnosis classically has the symptoms of haematuria and haemoptysis in a young person?

Answer 21

Goodpasture’s

Question 22

What is the likelihood of complete recovery of kidney function following an AKI if there is no pre-existing CKD?

Answer 22

80%

Question 23

Recall 3 ECG changes in hyperkalaemia

Answer 23

Tented T waves
Widening QRS complex
Small p waves

Question 24

What is the most common cause of nephrotic syndrome in adults?

Answer 24

Membranous glomerulonephritis

Question 25

What are the components of the annual review for patients with type 2 diabetes?

Answer 25

``` Retinopathy screening Foot assessment for both sensation and doppler testing of vascular supply Albumin:creatinie ratio U+E Serum cholesterol HBa1c Review of any glucose monitoring Weight assessment Smoking status assessment ```

Question 26

What are the indications for dialysis?

Answer 26

``` Refractory hyperkalaemia Refractory fluid overload Metabolic acidosis Uraemia symptoms CKD stage 5 ```

Question 27

What will the urinary sodium be in pre-renal vs intrinsic renal ARF?

Answer 27

Pre-renal: urinary sodium low | Intrinsic renal: urinary sodium high

Question 28

Recall the symptoms of HUS vs TTP

Answer 28

HUS: MAHA, thrombocytopaenia, AKI TTP: MAHA, thrombocytopaenia, AKI, neurological impairment and fever

Question 29

Recall some key nephrotoxic drugs that should be stopped in AKI

Answer 29

``` stop the DAMN drugs Diuretics ACEi and ARBs Metformin NSAIDs ```

Question 30

At what GFR would you do a routine nephrology referral?

Answer 30

Either at GFR <30 or a reduction in GFR over 12 months of >25% >15mL/min/1.73m^2

Question 31

How can CKD be managed by diet?

Answer 31

1. Reduce dietary phosphate, sodium, potassium, fluids 2. Sevelamar (phosphate binder) - reduces uric acid and lipid levels 3. Vitamin D

Question 32

Recall 4 features of adult polycystic kidney disease

Answer 32

Liver cysts Berry aneurysms Mitral valve prolapse Renal failure signs

Question 33

What is the medical management of adult polycystic kidney disease?

Answer 33

Tolvaptan

Question 34

Does IgA nephropathy cause nephrotic or nephritic syndrome?

Answer 34

Nephritic (rarely nephrotic)

Question 35

Recall some signs and symptoms of IgA nephropathy

Answer 35

Purpuric rash (100%) Arthralgia (60-80%) Abdominal pain (60%) Glomerulonephritis (20-60%)

Question 36

How should IgA nephropathy be managed?

Answer 36

Most cases will resolve spontaneously in 4w Joint pain --> NSAIDs Scrotal involvement/severe oedema/ severe abdominal pain --> oral prednisolone Renal involvement --> IV corticosteroids

Question 37

What type of cancer is left varicocele most associated with?

Answer 37

Renal cell carcinoma

Question 38

What is the most common form of renal tumour?

Answer 38

Clear cell carcinoma

Question 39

Which urological cancer is most associated with painless haematuria?

Answer 39

Transistional cell carcinoma

Question 40

In patients with CKD, what should be done before any scan that uses contrast?

Answer 40

Give IV saline --> volume expansion --> reduced chance of cast nephropathy