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Internal med 2 > 4) Chronic Kidney disease drug therapy > Flashcards

4) Chronic Kidney disease drug therapy Flashcards

1
Q

What is the UF coefficient

A

volume of ultrafiltrate per hour, divided by the pressure gradient across the membrane

ie the membrane’s effectiveness to filter the fluid.

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2
Q

Clearance

A

How many ml of blood is totally cleared of a given molecule in 1 minute.

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3
Q

Sieving coefficient

A

Membrane permeability of the membrane to a specific molecule

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4
Q

Surface

A

total surface of the capillary membrane in the unit

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5
Q

Blood volume

A

the amount of dialysed whole blood in mL

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6
Q

TMP

A

transmembrane pressure

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7
Q

TMP

A

transmembrane pressure

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8
Q

What are dialysis membranes made out of?

A

Cellulose 20 micron pore size

Cellulose acetate

Polyacrylonitrile, PAN

Polysulfone - 40 micron pore size

Polpropylene

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9
Q

What are the uremic toxins

A

Small MW toxins: purines, oxalate, myoinositol

Middle weight uremic toxins:
Beta-2 Microglobulin
Peptides
Advanced-glycation-endproduct proteins AGE-proteins
Variable peptides

Small MW solutes with ‘medium behavior’:
Homocysteine
Phenols
Chloramines

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10
Q

Anticoagulants used for hemodialysis, what are they

how are they administered

A

They are administered by the dialysis machine into the extracorporeal blood, prior to entering the dialysis capillary, preventing thrombosis from occuring in the machine.

Heparin - AT3 activation, thrombin inhibition

Hirudin; direct thrombin inactivator.

Citrate - calcium chelator

Prostacyclin - platelet inhibitor

Warfarin - VKOR inhibition

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11
Q

When are the anti-coagulants contraindicated during AKI or CKD?

A

Uremic pericarditis

Hypertensive crisis

Any acute cerebrovascular events/strokes

Gastroenteritis with bleeding danger

Proliferative diabetic retinopathy

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12
Q

Who should be referred to a nephrologist?

A

Nephrotic syndrome
Proteinuria or hematuria -everyone urgently

Urine Protein:Cre ratio: above 350mg/mM - everyone

UPCR above 100mg/mM - everyone except diabetics

UPCR above 45 mg/mM - if concurrent microhematuria or suspected autoimmune disorder.

Macrohematuria with proteinuria -urgently everyone

macrohematuria without proteinuria - refer if UTIs, urologic causes have been excluded.

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13
Q

What needs to be matched for organ transplant allocation

A

Blood group compatibility, ABO, Rh does not matter

HLA matching for
HLA-A HLA-B and HLA-DR
Human leukocyte antigen

Age,
Gender,
size

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14
Q

blood group compatibilities

How does this differ for allocation?

A

Donor: A
Recipient A or AB

Donor: B
Recipient: B or AB

Donor: AB
Recipient: AB

Donor: O
Recipient O or A or B

For allocation:
Group A donors can only go to A recipients, and Group A recipients can only receive from A donors.

Group O donors cannot go to A recipients

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15
Q

Allocation procedure

A

Donor typing from blood
Pre-cross match from sera of recipients

Selection based on waiting list priority:
Age, Urgency, highly immunized state

Is patient eligibility good? Contact patient and discuss

Recipient comes in and is examined.

Final crossmatch from the donor spleen and final decision

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16
Q

Determining actual eligibility

A

Vital parameters, is the patient stable

Renal exam, do they meet requirements for need

Surgical consult, exam. Can they withstand surgery.

Anesthesiological consult.

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17
Q

Preoperative care for renal transplant

A

Preoperative dialysis if needed.

Begin immunosuppression therapy

Antihypertensive therapy

PPI prophylaxis for ulcers

Antibiotic prophylaxis for infections

For patients with high sensitization/ Panel Reactive Antibodies, consider induction immunosuppression therapy, using monoclonal or polyclonal antibodies against T-cell receptors CD3.

18
Q

Kidney transplant placement
vessel attachments
ureter attachment

A

In the illiac fossa,

Connected to the common illiac artery and vein.
or external/internal illiac a. and v.

Ureter can be implanted directly onto a new site on the bladder,
or
Uretero-ureteral anastomosis.

19
Q

Types of donors

A

Cadaveric donor:
From brainstem-dead donors with beating hearts, on ventilation and circulatory support.
From non-heart heart beating donors - require more rapid retrieval.

Living related donors - Best option, well planed procedure, best HLA matching and graft survival

Living unrelated donors - often between spouces, have to meet the ULTRA requirements.

20
Q

Early post-op care for transplant

A

1-2 weeks post op.
General wound care and monitoring

Medications:
Immunosuppressants
Blood pressure
Blood sugar
Heparin - transitioning to NSAID
PPIs

Dialysis and renal biopsy if AKI/failure begins.

21
Q

Complications of renal transplantation

A 
Renal:
Rejection
Delayed graft function
Recurrent kidney disease
New kidney disease
Stones
Graft failure
Surgery complications
Extrarenal:
HTX
New onset diabetes mellitus
Dyslipidemia
Cardiovasular problems
Hematologic complications
Marrow suppression, pancytopenia
Osteopenia
Infections
Tumors
Delayed wound healing
Pyschological disorders, depression
22
Q

Common infections after transplants

A 
HSV
CMV
Hepatitis, HBV, HVC
EBV
VZV
Fungal infections
Nocardia
Toxoplasma
Cryptococcus
23
Q

Common tumors after transplants

A

Skin cancers are especially common.
sq. cell carcinoma,
melanoma,
baslioma

Other cancers incidence also all increase.

24
Q

What is PRA and sensitization

A

Panel Reactive Antibody (PRA) is an immunological laboratory test routinely performed on the blood of people awaiting organ transplantation. The PRA score is expressed as a percentage between 0% and 99%. It represents the proportion of the population to which the person being tested will react via pre-existing antibodies.

Higher sensitization, higher likelyhood for graft rejection.

25
Q

Graft survival estimates in years based on HLA mismatch

A

no mismatch: ~40% survival at 20 years, 17 year half life.

1 MM: 37%, 15 year half life
2 MM: 36%

6 MM: 29%

26
Q

Graft survival from siblings

A

60% survival in HLA matched siblings, 28 year half life

27
Q

Markers of graft survival

A

Renal function
Proteinuria

Emergence of donor-specific antibodies in patients serum - indicate onset of antibody injury to graft.
ex: anti-HLA abs, anti-non-HLA

Graft biopsy and histology for early or late rejection,

28
Q

Immunosuppressive drugs classes used after transplants,

Incidence of acute graft rejection

A

Acute rejection is ~10-15%

Steroids: Prednisolone

Antimetabolites: mycophenolate mofetil, azathioprine

mTOR-inhibitors: Sirolimus

Calcineurin inhibitors: cyclosporin

29
Q

Advantages of living donor over cadaveric donors

A

Kidney will immeidately function, and does not require a post-operative dialysis phase

Half life is 20 years instead of 13 years

1 year graft survival 95% instead of 90%

30
Q

How does the GFR change for the living donor?

A

Immediate drop to 50%,

then compensatory hypertrophy of the remaining kidney and increase back to about 70%

31
Q

What is the ‘safe’ GFR needed for a living donor to be eligible

A

based on the ERBP european renal best practice guideline.

Safe GFR ensures that by the best estimate, the patients GFR at age 80 will be at least 37.5

Before age 45, the donors GFR should be at least 80.

32
Q

Absolute contraindications for Renal transplantation

A 
Active infections
Active Glomerulonephritis
HIV
HBV
Cancer with likely metastases
Severe heart disease or other severe comorbidity, low survival.
33
Q

Relative contraindications for transplant

A

Age over 70

34
Q

1st line agents for treating blood pressure in CKD

Stages 1-3

A

ACEIs/ARBs and Loop diuretics (FUrosemide)

1st line: ACEIs or ARBs,

i. especially for diabetics with elevated ACR (>3mg/mM), microalbuinuria
 ii. Hypertension and ACR >30, proteinuria/nephrosis
iii. Any patient with ACR >70, severe nephrosis
iv. Dual therapy is contraindicated, just one.
35
Q

Treated blood pressure in CKD stage 4-5

A

ACEIs/ARBs, Furosemide, and add Thiazide or Spironolactone

Spironolactone contrad if eGFR <30
-spironolactone inhibits aldosterone receptors, and can cause hyperkalemia if GFR is too low.

36
Q

Duration of dialysis and rate of blood flow through the machine

Total extracorporeal blood during dialysis

A

4 hours for each treatment,
Blood is dialyzed at a rate of 200–400 mL/min

80-250mL extracorporeal

37
Q

Treatment of renal osteodystrophy

A

Phosphate control:

1) Limit phosphate intake
2) Treat with phsophate binders:
- CaCo3 and Ca-Acetate, CKD 3-5
- Sevelamer, Lanthanum, CKD 5d

Vitamin D supplementation:
Correct nay measured deficiency, give native vitamin D or active vitamin D.

Treat secondary hyperPTHism: administer calcimimetic drug to inhibit PTH release.

38
Q

Who should be referred to a nephrologist

A

GFR less than 15 unless it is pre mortem
GFR 15-29 always, urgenly if stable

GFR 30-60 and under aged 70 years

 - or eGFR falling more than 4ml/year
 - Hb < 110g/L or ion imbalance

GFR 60-90 if there is evidence of nephritis/nephrosis

39
Q

What must be matched/checked for allocation of a kidney transplant

A

Must be matched/have compatible ABO blood groups. Rh does not matter

Must have a negative crossmatch, mixing the patients serum with the blood of the donor and/or with cells from the donor. If the patients blood does not react to the donors then it is a negative, and the donoation can proceed.

HLA matching for the 6 HLA antigens is beneficial and higher matching will prolong the life of the donated kidney, but is NOT absolutely required for the transplant to occur, it is just strongly beneficial.

40
Q

blood type matching

A

Blood Type Compatibility Chart

Blood Type:	Can Donate To:
O	A,B, AB, O
A	A or AB (O)*
B	B or AB
AB	AB
Blood Type:	Can Receive From:
O	O (A)*
A	A or O
B	B or O
AB	A or B or AB or O

Internal med 2 (29 decks)

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