Top 5 kidney diseases leading to dialysis
1.Diabetes
2.GN
3.Vascular/HTN
4.ADPKD
5.Reflux
Benefit of balanced crystalloids in AKI
Less dialysis
Lower K
Less acidosis
also beneficial in transplant and in sepsis
Tumor lysis syndrome - electrolytes, risks, treatment
Rapid release of K, PO4, Ca, uric acid into the circulation
Risks: LDH, BM disease, high chemo radio sensitivity
Treatment
- IVT
- allopurinol - inhibits xanthine oxidase
- rasburicase - recombinant urate oxidase
IgA nephropathy treatment (4)
- Maximize RAS blockade + manage BP
- Address risk factors + lifestyle
- Consider SGLT2i
- Consider 6-months of steroids if at 90 days still 1g protein - avoid if high risk of SE: eGFR <30, diabetes, BMI >30, severe osteoporosis, cirrhosis, uncontrolled psych disorder, peptic ulcer, latent infection.
Offer clinical trials as no clear evidence
Management of GN complications - edema, hypertension, proteinuria, hyperkalemia, acidosis, hypercholesterolemia
Edema - loop diuretics + salt restriction
Hypertension - ACEi aiming <120/80
Proteinuria goal <1g/day
Hyperkalemia
- wasting diuretics: loop or thiazide
- potassium binders: petiromer, resonium
Metabolic acidosis HCO3<22 give sodium bicarbonate
Hypercholesterolemia - treat per guidelines - statin etc - decreased eGFR and albuminuria are independent CVD risk factors
GN not requiring biopsy - 2 definite plus 2 broad categories to consider with 7 conditions
Proteinuria in <12yo
Post-strept GN
Consider
- Membranous nephropathy with PLAR2
- PR3 or MPO positive vasculitis
- GBM with positive abs
- hereditary: Alport, fabry, familial fsgn
- SLE
When to consider (7) prophylactic anti coagulation in GN and agent of choice (3)
Albumin <20-25 AND one of:
1. Proteinuria >10g/day
2. BMI >35
3. Genetic
4. HF NYHA 3-4
5. Recent orthopedic or abdominal surgery
6. Prolonged immobilisation
Management
1. Warfarin
2. Heparin if hospital/ short term
3. Aspirin if albumin >32.
(DOAC do NOT have evidence and each have substantial renal clearance and albumin bound proportion which would impact dosing)
Membranous is high risk
Secondary causes of IgA nephropathy (4)
- Vasculitis
- Viral (HIV, Hepatitis)
- IBD and other autoimmune disease
- Cirrhosis
Elevated levels of soluble urokinase plasminogen activator receptor (suPAR) are associated
with which of the following renal conditions?
a. Membranous Glomerulonephritis
b. Focal Segmental Glomerulosclerosis (FSGS)
c. Membranoproliferative Glomerulonephritis (MPGN)
d. Minimal Change Disease
e. Anti-GBM Disease
Answer: B
Levels of suPAR have been found to be elevated in approximately 84% of adult patients with FSGS. suPAR has been shown to bind and activate podocyte β3 integrin, which leads to podocyte foot process effacement that is characteristic of proteinuric renal diseases.
All of the following situations may precipitate the formation and deposition of crystals in renal
structures leading to acute renal failure, EXCEPT:
a. IV acyclovir for severe herpes virus infections
b. Ethylene glycol toxicity or poisoning
c. Phosphate-containing laxatives in patients with CKD
d. Efavirenz used for HIV treatment
e. Tumour lysis syndrome as a result of cancer chemotherapy
Answer: D
Protease inhibitors Indinavir and Atazanavir used in HIV treatment can also lead to crystal nephropathies. However, Efavirenz has very minimal renal excretion in its active form. It is extensively metabolised in the liver by CYP450 3A4 and 2B6 systems and actually induces its own metabolism. Even when GFR is <10 mL/min or patients are on dialysis, it can be dosed as
in normal renal function.
In volume deplete patients, IV acyclovir is known to crystallize in red-green birefringent needle-
shape crystals that can block renal tubules.
Ethylene glycol toxicity and high doses of vitamin C
can both result in calcium oxalate crystal deposition in tubular cells and interstitium that can lead
to renal dysfunction.
Phosphate-containing laxatives may lead to acute phosphate nephropathy in patients with underlying renal impairment and hypovolemia.
In tumour lysis syndrome, uric acid crystallization in the tubules and collecting system may lead to a partial or complete obstruction of the collecting ducts, renal pelvis or ureter.
Minimal change disease (4)
- Nephrotic syndrome of childhood, but 10-20% adults
- Podocyte effacement on EM
- Adults relapse more
- Treat with prednisolone - 2nd line rituximab
Focal segmental GN (6)
- Nephrotic syndrome
- Hypertension +/- hematuria
- Glomerulosclerosis and hyalinosis effecting juxtamedullary nephrons first
- If persistent proteinuria then >50% will develop ESRF - fibrosis, hypertension, GFR also prognostic
- High recurrence in transplant (15-55%)
- Treat with prednisolone - 2nd line rituximab, cyclosporine
Primary membranous nephropathy (6)
- Nephrotic syndrome
- Thickened GBM with silver stain showing Ig deposits, spikes
- PLA2R - can guide investigation (secondary causes if negative) and treatment (based on titres and response)
- 25% ESRF in 10 years - nephrosis, HTN, Age, male, GFR
- Rituximab + steroids - 2nd line tacrolimus +/- MMF + pred
- Warfarin if albumin <20
IgA Nephropathy (6)
- Most COMMON nephritic syndrome
- Synpharyngitic
- Mesangial hypercellularity and matrix expansion. Interstitial damage and fibrosis with occasional crescents.
- 20% ESRF at 10 years - proteinuria, HTN, GFR, age, fibrosis
- ACEi + SGLT2i
- If minimal change overlap then prednisolone - otherwise risk outweigh benefit
Membranoproliferative GN (4) and treatment (4)
- Nephritic +/- nephrotic
- Secondary causes: hepatitis, Cryoglobulinemia, SLE, sjorgen’s etc (many)
- Membrane duplication = wire loops on silver stain, cellular proliferation, C3
- 40% ESRF at 10 years - nephrotic, GFR, interstitial disease
Treatment
5. If familial ACEi +/- SGLTi
6. If C3 - Eculizumab
7. If monoclonal treat for myeloma
8. If Hep C - sofosubivir/ velpatasavir
Rapidly progressive GN aka crescentic and subtypes (9)
- Renal failure
- Associated: hemoptysis, arthralgia/ myalgia, weight loss, lupus
- Crescents >50% glomeruli
- ANCA - most common, necrosis, eosinophils, pauci-immune
- GBM - linear IgG
- SLE - complement and granular antibody
- 50% ESRF - crescents, GFR
- Mortality due to pulmonary haemorrhage and sepsis
- Prednisolone pulse
- PO/IV cyclophosphamide or in ANCA use rituximab or in lupus use MMF
- Plasmapheresis for GBM, only in pulmonary haemorrhage for ANCA, NOT in SLE
Which risk factor best predicts development of renal failure?
A. Age
B. Smoking
C. Hypertension
D. Obesity
E. GFR<90
E
- GFR
- Diabetes
- Age
- HTN
- Smoking
- BMI
Most common cause of dialysis and most common GN leading to dialysis
- Diabetes
- GN - IgA most common
- HTN
- PKD
In a patient requiring urgent dialysis which of the following parameters would favour continuous renal replacement therapy (CRRT) rather than intermittent haemodialysis (IHD)?
A. Active bleeding.
B. Coagulopathy.
C. Hyperkalaemia.
D. Hypotension.
E. Hypoxia.
D - CCRT is gentler
67 y.o. diabetic on PD presents with abdominal pain, low grade fever and cloudy dialysate. She has mild generalised abdominal tenderness and guarding but does not appear particularly unwell. She is started on intra-peritoneal cephalexin. The next day, her dialysate culture grows:
Enterococci, E-coli and Klebsiella species.
The most appropriate management step is:
A. exploratory laparotomy.
B. add intraperitoneal Ampicillin.
C. removal of the Tenckhoff catheter.
D. intraperitoneal gentamicin.
E. change to intravenous antibiotics.
C
- 50% Gram positives = SKIN
- coagulase negative staph, staph aureus, enterococcus, streptococcus
- 15% Gram negatives = GUT
- 20% Culture negative = Don’t Know
- 4% Polymicrobial infection = Laparotomy/Remove Tenckhoff
- <2% Fungal infection = Panic and remove Tenckhoff
31% hospitalization i.e. most treated in the community
Treatment = gentamicin + cefazolin (replace with vancomycin if MRSA)
With regards to haemodialysis patients, survival is improved by?
A. Tight BP control
B. Tight weight control
C. Dialysis dose
D. Dialysis duration
E. Tight cholesterol control
D - longer duration = better survival
urea reduction ratio also associated with survival
old age = risk factor
Cardiovascular disease is the major cause of death in dialysis patients. Elevation of which of the following clinical parameters carries the highest mortality risk?
A. Serum phosphate.
B. Serum cholesterol.
C. Serum homocysteine.
D. Serum parathyroid hormone.
E. Blood pressure.
A - both PO4 and Ca are markers for mortality
- treatment with phosphate binders reduces mortality
- no association with PTH - though should treat with vitamin D +/- calcitriol
cholesterol has a paradoxical reverse association
BP in dialysis 120-170 equal risk - in practice aim <140
Which of the following is most likely to increase serum phosphate in chronic renal failure?
A. Calcium trisilicate.
B. Calcitriol.
C. Cinacalcet.
D. Calcitonin.
E. Alendronate.
B. Calcitriol
Vitamin D leads to increased absorption of Ca and PO4 in the gut and reabsorption in the kidneys
A 30-y.o woman presents with sustained HT (170/110 mmHg) on amlodipine monotherapy. Also on combined OCP. There is no radiofem delay or abdo bruit.
Investigation reveals the following:
Plasma renin activity <40 fmol/L/s [130-2350] Plasma aldosterone 320 pmol/L [80-1040] Serum potassium 3.9 mmol/L [3.5-5.5] Urinary metanephrines 1.3 μmol/24h [<1.5]
Which of the following secondary causes of HT is most likely?
A. ACTH-producing tumour.
B. OCP
C. Phaeochromocytoma
D. Primary hyperaldosteronism
E. Renal artery stenosis
D
