1
Q
How will you improve hyperkalaemia in CKD?
A
- Dietary restriction
- Avoid relevant meds (ACEI/spiro)
- Improve glycaemic control
- Correct metabolic acidosis
- Resonium
2
Q
DRILL = List CKD Hx
A
- Stage of CKD + proteinuria
- Diagnosis / presentation
- RFs / aetiology
○ DM
○ HTN
○ CVRFs
○ GN
○ PCKD - Course and previous Cx
- Current complications of CKD + Mx
○ Early stage = HTN, fluid overload, electrolytes
○ Later stage = anaemia, MBD, acidosis
○ ESRF = same as above but no acidosis - Current status
○ Symptoms: uraemia, restless legs, fatigue
○ Sx on dialysis: hypotension
○ Targets: fluid status and management, inter-dialytic gains
○ Adherence to lifestyle measures - Monitoring and future plans
3
Q
DRILL = Dialysis hx
A
- Duration + Indication
- Type of dialysis and prescription
- Access and any issues
- Adequacy of dialysis
○ Symptoms between sessions
○ Weight gain - Complications on dialysis
- CKD Cx + Mx
- Current status
○ Symptoms
○ IMPACT ON QoL
○ Targets / adherence - Monitoring / future plan ?Tx
- CVRFs
4
Q
What is your approach to treating this patient’s MBD in CKD?
A
- Mineral bone disease is important to address as it poses significant risk from CV risk due to vascular calcification, and also poses fracture risk
- To diagnosis, I would review CMP and PTH, Vit D
○ Secondary hyperPTH -> elevated phosphate, low-normal Calcium, elevated PTH secretion
○ Tertiary HyperPTH -> PTH persistently elevated despite high calcium - Targets
○ To normalise Ca and Phos
○ To keep PTH slightly elevated (2-6x normal) to avoid adynamic bone disease - Management
○ Secondary hyperPTH
§ Normalise Phos with binders + low phosphate diet
§ Review Ca, if still not normal after Phos Rx then give calcitriol
○ Tertiary hyperPTH
§ Parathyroidectomy if candidate
Cinacalcet (if not fit for surgery)
- To diagnosis, I would review CMP and PTH, Vit D
5
Q
How would you manage this patient’s renal anaemia?
A
- Renal anaemia is multifactorial ○ There is reduced EPO ○ There is iron deficiency ○ There is an Inflam state - I would rule out other contributors to anaemia - Optimise iron ○ Ferritin >100, Tsat >20% - Give EPO if Hb ~90 ○ Target 100-110 - If needing acute rise in Hb, may need to transfuse (EPO will take 4 weeks to work) ○ **very much try to avoid PRBC if renal Tx in the future - Contraindications ○ Solid organ malignancy
6
Q
When would you consider starting dialysis in this patient?
A
- Discussion about RRT are complex and should be commenced early on in CKD as it requires careful planning
- Dialysis is not for everyone, and can have a significant burden on people’s quality of life. It also may not be appropriate if this person’s life expectancy is short
- Ultimately it is vital to determine the patient’s priorities to see if RRT is appropriate rather than a supportive care approach, and if so then which modality
- With regards to RRT, a transplant is always a more favoured option for survival and QoL if it is an option for this patient, so this must be considered first
- Dialysis planning should commence before the urgent need arises, so I would be having these discussions and planning for access when the eGFR is ~15-20
- Need to consider access
○ Tenchkoff
○ AVF - Dialysis will ultimately need to commence if certain indications arise =
○ Serious manifestations of uraemia such as pericarditis or encephalopathy
○ If they are experiencing symptoms of uraemia such as nausea with malnutrition, significant malaise
If they have refractory overload or electrolyte/acid-base disturbances
7
Q
Is this person a renal transplant candidate?
A
This person is nearing the end stages of CKD, and without RRT of some kind, their life will be cut short.
With regards to a transplant for this person, I can identify a number of barriers =
- I am concerned about their safety for surgery from an anaesthetic / obesity perspective - Risky to immunosuppress -> infection / malignancy - Concerns with adherence to necessary transplant care -> substance abuse, uncontrolled psychiatric disease, social isolation, previous non-adherence - Concern about the limited benefit which they may receive from this transplant, as they have serious other co-morbidities and a shortened life expectancy
Some of these can be addressed but will need a multidisciplinary approach and detailed discussions with the transplant team.
8
Q
How would you evaluate for renal graft dysfunction / rising Creat?
A
- DDx = ○ Usual approach to AKI § Pre / intra / Post ○ Acute Rejection ○ CAN ○ Infection (BK / other) ○ Recurrence of old pathology ○ CNI toxicity - Ix ○ Bloods -> renal fx, inflam markers ○ Urinalysis to look for active sediment ○ MCS ○ Renal USS + doppler - BIOPSY definitive
9
Q
How are you going to slow progression of this person’s CKD?
A
- Frequent monitoring and follow-up
- Address underlying cause of CKD (DM, HTN, treat GN)
- Manage CVRFs
• Lifestyle
○ Smoking cessation
○ Optimal Weight BMI 20-25
○ Physical activity (>30 min /day)
○ Nutrition: Dietary salt intake restriction, limit EtOH, Protein restriction (optimal level not determined in ESRD aim 1.2g/kg/day and 35kcal/kg/day)
• Clinical Factors
○ BP <130/80
○ Reduce proteinuria: goal <1g/day or aim reduction of proteinuria ~50-60% from baseline plus protein excretion <3.5g/day (ACEI/ARB)
○ Cholesterol: Total <4mmol/L and LDL <2mmol/L (diet and statins)
○ Blood glucose: Pre-prandial 4.4-6.7mmol/L and HbA1c <7% (lifestyle/HA/Insulin)
10
Q
Which type of dialysis are you going to recommend?
A
- The decision about dialysis modality is one that really hinges on the patient’s priorities and preferences, as well as any specific contraindications
- In my discussion with the patient, I would also involve a Dialysis Educator who can begin to form a relationship and advise on intricacies of modalities
- As a starting point, I would generally recommend PD for its flexibility and lesser impact on lifestyle, as it can be done at home overnight
○ It also has benefits of preserving native urine output for longer, and is gentler for the heart
○ However they need to have an appropriate peritoneal membrane, and have the dexterity and eyesight to perform the task
○ It may also pose a risk in uncontrolled diabetes with dextrose in PD fluid - If Home HDx is an option this can also be explored, although this can be tricky in terms of needling at home and ensuring an appropriate set-up in the house
- Otherwise satellite HDx is our other option
○ I would liaise with my Vascular colleagues to assess vein mapping and ensure that an AVF is able to be created in this person
○ This needs months to mature so needs to be well-planned
In this patient _____(what I would recommend)
11
Q
How would you evaluate this person for transplant suitability?
A
There are many considerations which will impact this person’s transplant, which require a detailed evaluation.
- From a pre-operative perspective ○ Status of underlying condition must be controlled ○ We need to do an Infection screen to look for any co-morbid conditions or those at risk of re-activation § Co-morbid infections □ HCV / HIV § Risk of re-activation □ HBV (do they need prophylaxis with entecavir? -> if HbsAg +ve) □ Quantiferon / Strongoloides if RFs □ CMV status, EBV § Vaccination status ○ Malignancy where relevant, ensuring UTD with age-appropriate screening - Then it is important for us to consider the peri-operative anaesthetic risk § Cardio § Resp
Then with regards to their post-Tx course, I would ensure detailed evaluation as to their psychological wellbeing and social supports in order to ensure they can adhere to the rigours of caring for a transplanted organ
12
Q
What is microalbuminuria and what is macroalbuminuria?
A
Males
Micro = 2.5 - 25 mg / mmol Macro = >25 mg / mmol
*Females replace 2 with 3
13
Q
DRILL = Renal Transplant History
A
- Indication, brief history
- Donor
○ Live related / unrelated
○ Deceased type - Procedure + immediate Cx
- Course
○ Rejection + Mx
○ Current status of function - Immunosuppression
○ Specific AEs
○ Infections + prophylaxis / vaccinations
○ Malignancies
- Donor
2020 Long Case Nosh
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