Chronic Kidney Disease (CKD) Flashcards

Question

What are the problems with phosphate binders

Answer 1

Phosphate binding a difficult concept to explain to patients Patient may not feel benefits of phosphate lowering and poor adherence Efficacy relies on dose timing before or with meals High tablet burden GI intolerance Dose increases or binder changed because patients don't declare poor adherence

Answer 2

1. Ongoing stimulation of parathyroid glands causing them to become enlarged and being to function autonomously- continue to secrete PTH even if hypocalaemia is corrected 2. PTH levels extremely elevated 3. Increased bone turnover (demineralisation)- calcium and phosphate released from bone 4. Hyperphosphataemia exacerbated (worsens) 5. Hypercalcaemia can occur 6. Treatment: cinacalcet or parathyroidectomy

Answer 3

1. Calcimimetic agent 2. Increases sensitivity of calcium sensing receptors to extracellular calcium 3. Inhibits release of PTH 4. Recommend: PTH > 85pmol/l with hypercalcaemia In whom surgical parathyroidectomy removal is contraindicated 5. Dose- 30 to 180mg per day orally 6. Nausea can be a problem and important to monitor calcium

Answer 4

Increased fracture risk Bone and joint abnormalities Bone and muscular pain Vascular and soft tissue calcification (increased CVD)

Answer 5

1. Occurs when quality of quantity of RBC are below normal 2. Haemoglobin concentration: Men <13.0g/dl Non-pregnant women <12.0g/dl 3. Causes: Stress ulceration of chronic disease (minor GI losses) Chronic HD- loss in circuit Sampling losses- multiple blood tests Reduced RBC survival Dietary inadequacy- dietary restriction to reduce phosphate intake and anorexia due to nausea of uraemia Poor iron absorption- due to PPI or phosphate binders or uraemia Reduce erythropoiesis Impaired erythropoiesis- in presence of adequate erythropoietin and iron - infection/inflammatory state - ACEi/ immunosuppresants - Decreased folate/ vitamin B12 intake - Secondary hyperparathyroidism

Answer 6

Kidneys are the primary source of erythropoietin (EPO) and is a glycoprotein hormone that tells bone marrow to produce RBC Production of EPO is stimulated by drop in blood oxygenation (hypoxia) Circulating plasma EPO is low- usually occurs when eGFR falls below 30ml/min CKD kidneys don't make enough EPO

Answer 7

Produce identical response to EPO normally produced by kidneys- tell bone marrow to produce RBC Examples: NeoRecormon and Eprex- recombinant Human Erythropoietin Aranesp- novel erythropoiesis stimulating protein- longer half life than HuEPO Mircera- longer half life that provides continuous receptor activity

Answer 8

``` Increase in: Quality of life Exercise capacity Endocrine function Immune function Muscle metabolism Sleep patterns Sexual function Cognitive function Nutrition ``` ``` Decrease in: Cardiac output Depression Hospitalisations Bleeding tendency Transfusions angina LVH ```

Answer 9

Adults, young people and children >2years of age

Answer 10

Iron should be optimised before or coincident with initiation of ESA administration and during maintenance treatments with ESA

Answer 11

1. Serum ferritin correlates with tissue ferritin (contains iron) and reflects total available iron stores 2. Caution in inflammatory states like CKD especially those on dialysis in whom sub clinical inflammation is present (raised CRP) 3. Transferrin carries iron between stores of reticula-endothelial system to erythropoietic cells in bone marrow 4. Transferrin saturation (TSAT) provides a good indicator of iron available for erythropoiesis

Answer 12

Insufficient iron stores characterised by low Ferritin CKD < 100ng/mL (<200ng/ml in HD) Non CKD <30ng/ml May be corrected by oral iron

Answer 13

Inability to mobilise iron from liver and other storage sites to bone marrow for erythropoiesis Characterised by: Ferritin > 100ng/mL TSAT < 20% Common problem in CKD Requires intravenous iron to respond to administered erythropoietin and correct anaemia

Answer 14

Advantages Inexpensive Not associated with severe adverse effects Disadvantages GI side effects common Variable GI absorption Patient groups: Pre dialysis CKD- oral iron considered Peritoneal dialysis- limited efficacy Haemodialysis- unsuitable

Answer 15

Ferinject- single dose of iron, 1g at a time, 1g per week Side effects: Hypersensitivity reactions Anaphylaxis

Answer 16

Aranesp- initiate at low dose Eprex/NeoRecormon- shorter half life 4000 units SC once weekly starting dose Mirecera- monthly dosing

Answer 17

Side effects: Hypertension PRCA (pure red cell achalasia)- rare Increases Hb rate by 1-2g/dL/month Monitor Hb 2 to 4 weekly in induction phase 1-3 monthly in maintenance phase Minimum interval adjustments between ESA dose is 2 weeks because of the effect most dose changes will have Dose adjustments of 25%

Answer 18

New solution- glucose solution Tubing Set Used Solution Exchange of peritoneal space in dialysis and can be discarded

Answer 19

1. Solution left to dwell for 4-6 hours during which time patients can be left to dwell for 4-6 hours which time patients can continue with their daily activities 2. Exchanges take place 30-40 minutes and are performed 4 times a day

Answer 20

Performed overnight enabling patients to be dialysis free in a day

Answer 21

Peritonitis: aseptic technique essential when performing exchanges Diabetes; secondary to high glucose concentration of dialysate Sclerosing Peritonitis: Thickening of peritoneum that encloses small intestine (can cause partial or complete small bowel obstruction)

Answer 22

Independence and freedom for patient Carried out at home or work Skilled nursing only required for initial training Maintain access Continuous- less fluid and diet restrictions Do not need to go for dialysis 3 times a week

Answer 23

Motivated and competent patient Not as efficient as haemodialysis Albumin loss

Answer 24

Connecting patients circulations to dialysis machine to create a haemodialysis circuit via - Arteriovenous fistula (AVF)- removes blood and feed blood into dialysis machine - Central venous catheter (CVC) Blood in haemodialysis circuit is pumped through a dialyser Dialyser is composed of thousands of hollow synthetic fibres whose walls act as a semi-permeable membranes Blood flows through fibres and dialysis solution around outside of fibres (opposite direction)- allows toxins to be exchanged and removed in blood Water and waste products (phosphate and potassium) move between two solutions

Answer 25

1. Diffusion- movement of solutes from fluid with high to low concentration - Removes waste products - Essential minerals replaced e.g. bicarbonate 2. Ultrafiltration- movement of fluid under pressure - Application of negative pressure to dialyse compartment of dialysed to allow removal of several litres of water and dissolved solutes to remove from blood

Answer 26

Very efficient Better for less motivated patients- not motivated at home

Answer 27

Fluid and diet restrictions- high protein for higher albumin levels, low salt diet and reduced potassium and phosphate Rapid changes in fluid and electrolytes Limiting freedom- 3 times a week in hospital Expensive (NHS) Need continuous skilled nursing care Blood loss- dialysis process loses blood Access- clotted or infected fistula

Answer 28

``` Advise: Medication Dosing Administration- injectables, fluid restriction Interaction checks Timing of dosing Effect of dialysis on dosing ``` Patient counselling Teaching sessions- staff and patients Developing clinical guidelines Multi-disciplinary work- outpatient clinic and ward based Finance reporting Directorate meetings Risk management Error reporting and investigation Formulary submissions for new drugs Research Audit