Chronic renal failure Flashcards
Management overview
- Diet: Protein restriction with adequate calories K+ restriction Na and water restriction Phosphate restriction Avoid extra-dietary magnesium (antacids)
- Medical: Treat secondary hyperPTH Calcium supplements Calcitriol Phosphate binder Vitamin D analogues Cinacalcet for hyperparathyroidism (sensitizes parathyroid to Ca2+, decreasing PTH) Sodium bicarbonate EPO ejections ACEi Statins Adjust medications Stop nephrotoxic medications. Statin therapy. Optimise diabetes management.
- Dialysis
- Renal translpant
Prevention of progression
- As management 2. Control HTN, DM, smoking cessation, physical activity, weight loss 3. Avoid neprhotoxins 4. Address reversible causes of AKI
Presentation of renal failure
- Volume overload 2. Electrolyte abnormalities 3. Uremic syndrome
Complications of renal failure
Complications
- CNS: decreased LOC, stupor, seizure
- CVS: cardiomyopathy, CHF, arrhythmia, pericarditis, atherosclerosis
- GI: peptic ulcer disease, gastroduodenitis, AVM
- hematologic: anemia, bleeding tendency (platelet dysfunction), infections
- endocrine: decreased testosterone, estrogen, progesterone increased FSH, LH
- metabolic: renal osteodystrophy: secondary increased PTH due to decreased Ca2+, high PO4 3- and low active vitamin D osteitis fibrosa cystica, hypertriglyceridemia, accelerated atherogenesis, decreased insulin requirements, increased insulin resistance
- dermatologic: pruritus, ecchymosis, hematoma, calciphylaxis (vascular Ca2+ deposition)
Indications for dialysis
HAVE PEE or AE IOU
Hyperkalemia (refractory)
Acidosis (refractory)
Volume overload (refractory)
Elevated urea (>35-50 mM)
Pericarditis
Encephalopathy
Edema (pulmonary)
Number of people on RRT, number at risk of CKD, number of people with CKD
- 1 in 1500 on RRT
- 1 in 9 CKD
- 1 in 3 at risk of CKD
Risk factors
- >60
- ATSI
- Diabetes
- CVD
- hypertension
- smoking,
- diabetes FHx,
- obesity–>screen in adults >35 with
risk
Screening for CKD in ATSI
- Screen for risk factors annually in 18-29 yo
- All >30, 18-29 w/ risk factor: urine ACR, eGFR, BP every 1-2 years
Systemic manifestations
- Fluids and electrolytes: +K, deH, edema, metabolic acidosis, +Urea/Creatinine
- Calcium, Phosphate and bone: renal osteodystrophy, secondary hyperPTH, hypocalcemia (-ve conversion vit D, -ve absorption in GIT, acidosis), hyperphosphatemia
- Sexual dysfunction
- Hematological: anemia (-ve EPO, blood loss due to defective PLTs), hemolytic
- Cardiopulmonary: Pulmonary edema, cardiomyopathy, pericarditis, HTN
- GIT: NVD, esophagitis, gastritic, colitis
- Neuromuscular: myopathy, peripheral neuropathy, encephalopathy
- Dermatologic: Sallow colour, dermatitis, pruritis, nodules
Renal replacement therapy in acute setting indications
- Metabolic acidosis
- +K >6 despite other management
- +plasma urea and creatinine
> 30 mmol/L (180 mg/dL) and creatinine
> 600 μmol/L (6.8 mg/dL) - Fluid overload w/ complications->pulmonary edema, heart failure
- Uremic pericarditis/encephalopathy
Hemofiltration or hemodialysis
Renal replacement therapy chronic: reasons for one over the other
- Hemodialysis: more hemodynamically stable, more time consuming, must be in hospital, time away. Needs increased compliance with diet and fluids.
Risks: hemodynamic instability, bleeding, sepsis, hypersensitivity, air embolus, arrythmias
- Peritoneal: more comfort, in own home, diet less restrictive. May not have suitable living, not stable household, non compliance, infection risk
Complications and associated management: HTN, bone, albuminuria, glycemic control, anemia
- HTN: a) Lifestyle b) ACEi first line, aim <130/80 in diabetic, 140/90 in others. Monitor eGFR/K. Cease if eGFR drop >25% in 2 months and reconsider/refer. If K 6-6.5 lower, K wasting diuretic, K diet restricting. If then X<6->stop and consider BB, CCB, thiazide. >6.5= emergency
- Bone: Keep Phosphate and Ca in normal range, PTH 2-9 X upper limit, vitamin D.
Phosphate diet restriction (get dietician help)-> cheese, milk, eggs, use phosphate binders (Calcium carbonate)
Consider calcitriol in later stages.
If phosphate controlled, calcium leves usually improve.
- Albuminuria: ACEi, ARB, reduce salt, use spirinolactone cautiously
- Glycemic: Pre-prandial BSL 4.0-6.0 mmol/L
HbA1c <7.0%/53mmol/mol
Hypoglycemics, diet, insulin, incretins, gliptins
- Anemia:
Hb 100 – 115 g/L
Prior to commencement of epoetin: Ferritin > 100 μg/L
TSAT >20%
Once epoetin commenced: Ferritin 200-500 μg/L
TSAT 30-40%
Need neprhologist.
Iron supplement
Rule out other causes->Vit B12, folate, TSH
Mangement of complications: uremia, restless leg, hyperkalemia, sleep apnea, depression, acidosis
- Uremia
Dialysis when urea ++
Low protein diet, fluid control
Antiemetics have limited value
- Restless leg
Iron supplementation, baths and massages, compresses, levodopa, benzodiazepines
- Hyperkalemia
Low K diet, correct acidosis, K wasting diuretics, resonium A powder, cease ACEi/ARB/Spirinolacton if >6.
- Acidosis
?Sodium bicarbonate
- Sleep apnea
Weight loss
Avoid CNS depressants
CPAP
- Depression
Psychosocial intervention
Antidepressants at low dose
Medications in CKD: drugs needing reduction, affects on kidney
- Dose reduction
Anticoagulants–>dabigatran
Antivirals
Benzodiazepines, gabapentin, lithium
Colchicine
Digoxin
Exenatide, insuin, metformin
Sotolol, spirinolactone
Sulfonylureas
Opioid analgesics
Digoxin, fenofibrate
Saxagliptin (DPP-4 inibitors)
- Adverse effects
Contrast
NSAIDs, COX 2 i, ACE, diuretics->tripple whammy
Aminoglycosides
Lithium
Calcinuerin
Definition
- eGFR <60 w/o signs of kidney disease or evidence of kidney damage-> albuminuria, hematuria, structural, pathalogical
- Present for >3 months
Screening test for CKD
- urinary ACR measurement in a first void spot specimen=
best measure for albuminuria,.not possible: can use
random spot test–> repeat to confirm persistence - if abnormal need 2 of 3 abnormal readings over 3 months
DIfferential for +ACR
UTI- dipstick, Acute febrile illness - T
+Dietary protein- Hx, ++exercise last
24 hours- Hx
Mensturation/vaginal discharge- Hx
NSAIDS- Hx, Congestive, cardiac failure
Is eGFR clinically reliable
- No, dependent on age
- +muscle under, -ve muscle over
- +Protein, vegetarian, creatine supplements interfere
- Extremes of body size
If abnormal eGFR
- Urine ACR
- eLFTs
- Serum creatinine
- FBC
- Lipids, glucose
- Urine MCS
- Refer to neprhologist when GFR <30, drop in baseline 60
by >5 over 6 months confirmed by 3 readings
Glomerular hematuria w/ macroA
CKD + HTN not ocntrolled despite three antihypertensive
Management action plans: yellow, orange, red
- Yellow >60 w/ microA, >40-59
Annual review:
a) exclude treatable, adress CVD, avoid nephrotoxic drugs
b) BP, lifestyle
c) Urine ACR, UEC, BUN, eGFR, HbA1C, statins
2. Orange 30-60 w/ micro >30-44
3-6 monthly
a) Same as yellow + detect complications, adjust medication doses, refer when indicated
b) +FBC, CMP, PTH when <45 + Urine ACR, UEC, BUN, eGFR, HbA1C, statins
3. Red action plan
MacroA, eGFR <30
1-3 monthly review
a) Same goals, + referall + prepare for dialysis + AHD
b) Same investigations + edema, +advanced care planning
Stages
Stage 1: kidney damage with normal or increased GFR, ≥90 mL/minute/1.73m^2
Stage 2: kidney damage with mild decrease in GFR, 60 to 89 mL/minute/1.73m^2
Stage 3a: kidney damage with moderate decrease in GFR, 45 to 59 mL/minute/1.73m^2
Stage 3b: kidney damage with moderate decrease in GFR, 30 to 44 mL/minute/1.73m^2
Stage 4: kidney damage with severe decrease in GFR, 15 to 29 mL/minute/1.73m^2
Stage 5: kidney failure (end-stage kidney disease), with GFR <15 mL/minute/1.73m^2
Define acute renal failure
Acute kidney injury is defined by a rise in the serum creatinine of ≥23 micromol/L (≥0.3 mg/dL) from baseline, a 50% increase in serum creatinine from baseline, or a reduction in urine output of <0.5 mL/kg/hour for more than 6 hours that occurs over a period of days to weeks.
Counselling use of ACEi
- Used to treat hypertension, block conversion of angiotensinogen to angiotensic 2, also inhibit bradykinin breakdown.
- Avoid in pregnancy.
- Common adverse effects: hypotension, headache, dizziness and cough. Also hyperkalemia, fatigue, nausea, renal impairment
- Infrequently cause rash, angioedema, diarrhea and elevated LFTs
- Cough is a persistent, non-productive. Not dose dependent, unlikely to respond. Some may need to stop.
- May feel dizzy, get up slowly
- Do not take potassium supplements, unless required.
- when starting an ACE inhibitor:
stop potassium supplements and potassium-sparing diuretics
in heart failure, consider reducing dose or withholding other diuretics for 24 hours before starting an ACE inhibitor
review use of NSAIDs (including selective COX‑2 inhibitors)
start with a low dose
check renal function and electrolytes before starting an ACE inhibitor and review after 1–2 weeks
