CKD Flashcards
1
Q
What happens to nephrons in chronic kidney disease (CKD)? What characterises abnormal kidney function in CKD?
A
Irreversible loss
Leaking protein or blood
2
Q
Why is CKD often unrecognised? What are the causes of CKD?
A
No specific symptoms or asymptomatic
Inherited or acquired
3
Q
What conditions often coexist with CKD? What can treatment do for CKD?
A
CVD and diabetes
Prevent or delay progression, reduce complications, reduce CVD risk
4
Q
What happens to coexisting conditions as kidney dysfunction progresses? What can CKD progress to in a small percentage of people?
A
Become more common and increase in severity
End-stage kidney disease
5
Q
What happens when kidneys don’t work properly?
A
Fluid retained, BP rises, waste builds up, electrolytes deranged
6
Q
What do uraemic toxins accumulating lead to?
A
Fatigue, nausea, anorexia, lethargy, weight loss, pruritus, frothy urine, taste disturbance
7
Q
In CKD stages 4 & 5, what conditions are present?
A
Hyperkalaemia, uraemia, anaemia, impaired vitamin D metabolism
8
Q
What does impaired vitamin D metabolism lead to?
A
Hyperparathyroidism, hypocalcaemia, hyperphosphataemia, affecting bone turnover
9
Q
Approximately what percentage of the UK population has some degree of chronic kidney disease?
A
Approx. 13%
10
Q
What percentage of patients present late with ESRD? Late presentation with ESRD causes what?
A
Approx. 19%
Significant individual, societal and NHS costs
11
Q
CKD increases the risk of what?
A
Stroke and CVD
12
Q
What is the KDIGO 2012 classification? What does the suffix ‘P’ denote in the KDIGO classification?
A
- Risk of CKD
Low risk to very high risk - Significant proteinuria at any stage
13
Q
How should eGFR be estimated? What correction factor should be applied to GFR values for people of African-Caribbean or African family origin?
A
Using the GFR-EPI creatinine equation
Multiply eGFR by 1.159
14
Q
How does reduced/increased muscle mass affect GFR? How long should meat consumption be avoided before eGFR test? How long should a blood sample be processed in for an eGFR test?
A
Overestimation/underestimation
12 hours
12 hours
15
Q
What is the advantage of the eGFRcysC test? What is the eGFRcysC test based on?
A
More sensitive
Cystatin C
16
Q
How is cystatin C handled by the kidneys? What is the impact of uncontrolled thyroid disease on eGFRcystatinC values? Which proteinuria test should be used?
A
Filtered by glomerulus, completely reabsorbed by tubules, and catabolised
Falsely elevated in hypothyroidism, reduced in hyperthyroidism
ACR
17
Q
With the KDIGO classification, going from green to red, there is an increased risk of what?
A
ESRD, worsening eGFR, increased all-cause mortality
18
Q
Why is early diagnosis and investigation important in those with CVD? How often should eGFR be measured in at risk groups?
A
They have higher CVD risk, and may progress to ESRD
Annually
19
Q
When should eGFR be tested in chronic kidney disease patients? When can the frequency of eGFR testing be reduced?
A
During intercurrent illness and perioperatively
eGFR levels remain very stable
20
Q
How should eGFR progression be monitored?
A
Measuring 3 eGFRs spread over at least 3 months
21
Q
How is progressive CKD defined?
A
Fall in eGFR of 25% and change in eGFR category within a year or Sustained fall in eGFR of 15ml/min/1.73m2 per year
22
Q
What are the risks of progressive CKD compared to stable eGFR? What ethnicities are risk factors for progression of CKD?
A
4 – 5 times more likely to develop ESRD, 1.5 – 2 times increased risk of dying
African, African-Caribbean or Asian
23
Q
What lifestyle factors are risk factors for progression of CKD? What are other factors?
A
Smoking
Hypertension, CVD, diabetes, proteinuria, AKI, untreated urinary outflow obstruction, long term use of NSAIDs
24
Q
How many eGFR tests are needed to diagnose CKD? How can you slow the progression of CKD?
A
At least 2 eGFR tests taken 3 months apart
Controlling BMs, BP, and reducing proteinuria
25
What is the target BP for CKD alone? What is the target BP for CKD + diabetes?
<140/90mmHg
<130/80mmHg
26
When should you offer a low-cost renin–angiotensin system antagonist to people with CKD?
Diabetes and an ACR of 3 mg/mmol or more; Hypertension and an ACR of 30 mg/mmol or more; An ACR of 70 mg/mmol or more
27
How do ACEi or ARBs reduce rate of progression?
Preferentially reducing intraglomerular pressure, and lower proteinurea
28
What should you do with the dose of renin–angiotensin system antagonists if the GFR decrease from pretreatment baseline is less than 25%?
Do not modify the dose
29
What should you do with the dose of renin–angiotensin system antagonists if the serum creatinine increase from baseline is less than 30%?
Do not modify the dose
30
What should you do if there is a decrease in eGFR or increase in serum creatinine after starting or increasing the dose of renin–angiotensin system antagonists, but it is less than 25% (eGFR) or 30% (serum creatinine) of baseline?
Repeat the test in 1–2 weeks. Do not modify the dose
31
What should you do if the eGFR change is 25% or more, or the change in serum creatinine is 30% or more?
Investigate other causes, and stop or reduce the dose
32
What does good glycaemic control reduce the development of?
Microalbuminuria
33
When can bisphosphonates be used? What drugs should be offered to people with CKD for the secondary prevention of cardiovascular disease?
eGFR ≥ 30
Antiplatelet drugs
34
What drugs should you offer to people with CKD? What supplements should you offer if vitamin D deficient?
Statins
Colecalciferol or ergocalciferol
35
When should you consider alfacalcidol or calcitriol in CKD? When should you consider oral sodium bicarbonate supplementation?
If eGFR <30 ml/min/1.73m2
GFR less than 30 ml/min/1.73 m2 and a serum bicarbonate concentration of less than 20 mmol/litre
36
When should you consider apixaban in preference to warfarin in CKD? What are some risk factors for apixaban use?
1. Confirmed eGFR of 30–50 ml/min/1.73 m2 and non-valvular atrial fibrillation with 1 or more of the risk factors
2. Prior stroke or transient ischaemic attack, age 75 years or older, hypertension, diabetes mellitus, symptomatic heart failure
37
What are the main complications of CKD?
CVD, anaemia, bone and mineral disorders
38
In CKD, when is Hb < 110 g/L primarily due to?
EPO deficiency
39
What is EPO responsible for?
Proliferation and differentiation of erythroid progenitor cells in the bone marrow, which in turn is responsible for the production of RBC
40
What are potential causes of anaemia? What are the symptoms of anaemia?
1. Blood loss during dialysis, shortened life span of RBC, impaired iron haemostasis, inflammation, secondary hyperparathyroidism
2. Tiredness, shortness of breath, lethargy and palpitations
41
What can anaemia impair? How should iron deficiency be managed?
QoL and increasing risk of CV complications
As per normal to a max ferritin level of < 800 micrograms/L
42
How is iron administered during dialysis? What do iron and ESA treatment do?
IV
Decreases patient fatigue, and has also been found to reduce hospitalisation and the need for blood transfusions
43
What are Erythropoiesis stimulating agents (ESAs)? What do ESAs improve?
Biological that stimulate EPO
Survival, reduces CV morbidity, enhance QoL
44
How are ESAs administered? What happens to some patients when given ESAs? When do ESAs not work?
1. EPO IV for HD during dialysis, SC for PD
2. Some patients are resistant to ESA treatment, and they have to depend on blood transfusions
3. For patients with high CRP
45
What should be the Hb aim in CKD?
Between 100 – 120 g/L
46
What is an ADR of pure red cell aplasia?
Reported leaving patients dependent on blood transfusion
47
What are some ADRs of ESAs?
HTN, seizures, allergic reactions
48
Extraskeletal calcification occurs when? Mineral and bone disorders can begin to appear from what stage? What do mineral and bone disorders manifest in?
Increasing risk of CVD
Stage 3 onwards
Abnormalities in Ca, PO4, PTH, vitamin D metabolism, bone turnover, mineralisation, volume, growth and strength
49
Early CKD, PO4 excretion is what? As CKD progresses, what happens to PTH's ability to excrete PO4?
Reduced
Diminishes and PO4 levels rise
50
What does reduced PO4 trigger?
Compensatory increase in PTH secretion stimulating kidneys to excrete more PO4
51
Renal hydroxylation of inactive calcidiol to the active form of vitamin D (calcitriol) is what?
Reduced
52
What does hyperphosphataemia, hypocalcaemia and low calcitriol trigger? How should hyperphosphataemia, hypocalcaemia and low calcitriol be treated?
1. Stimulation of PTH synthesis and secretion [secondary hyperparathyroidism]
2. By correcting calcium, phosphate and vitamin D
53
What does reduced hydroxylation lead to?
Reduced intestinal absorption of calcium and then hypocalcaemia
54
How can phosphate be removed from the body? How do phosphate binders work? When should phosphate binders be taken?
Dialysis
Reducing GI absorption of phosphate from food
Before, with or soon after food for maximum efficacy
55
What is the dose frequency of Sevelamer? When should Sevelamer be taken? What does Sevelamer do to cholesterol levels?
3x800mg
With food
Lowers them
56
What condition's progression is slowed by Sevelamer? What is a notable disadvantage of Sevelamer? Which of these is a side effect of Sevelamer? What condition is lessened by Sevelamer?
Extraskeletal calcification
High pill burden
Constipation
Hypercalcaemia
57
What are important counselling points to consider with phosphate binders?
- Take with food
- Calcium carbonate and lanthanum must be chewed
- Sachets of lanthanum can be sprinkled on food
- Calcium acetate and sevelamer must be swallowed whole
- Sevelamer sachets must be dispersed in 60ml of water
- Patients may split their binders up based on phosphate in food
58
What condition can vitamin D replacement help with secondarily?
Hyperparathyroidism
59
What does vitamin D replacement help correct? What is a risk of vitamin D replacement? What is a risk of over-supplementation of vitamin D?
Hypocalcaemia
Hyperphosphataemia
Oversuppression of parathyroid
60
What class of medication is Cinacalcet? What does Cinacalcet increase the sensitivity of?
Calcimimetic
Calcium-sensing receptor
61
Where are the calcium-sensing receptors that Cinacalcet acts on located? What deos Cinacalcet inhibit? What are the effects of Cinacalcet?
Parathyroid glands
PTH release
Reducing calcium and phosphate
62
What are the two types of Parathyroidectomy?
Sub-total or total
63
What does total parathyroidectomy require?
Lifelong calcium supplementation
64
At what GFR level should a patient be referred to a low clearance clinic? When is Renal Replacement Therapy (RRT) considered?
20ml/min
GFR <10ml/min
65
What are the two types of kidney transplant donors?
Living or deceased donor
66
What condition occurs with both acute and chronic renal failure?
Metabolic acidosis
67
What causes metabolic acidosis in renal failure? What is the typical plasma bicarbonate level in renal failure with acidosis? What is important in limiting the fall in bicarbonate during metabolic acidosis?
Failure of excretion of acid anions
12-20mmol/L
Intracellular and bone buffering
68
What is the name for loss of bone mineral due to bone buffering? What is a consequence of bone buffering?
Osteomalacia
Loss of bone mineral
69
How are medicines eliminated by the kidneys affected by CKD? How are medicines metabolised to inactive compounds affected by CKD?
Reduced clearance and prolonged half-life
Not affected
70
What treatments are appropriate for Hypertension, and what target should be aimed for in CKD?
Offer ACEi or AT1RA
Target <140/90 mmHg
Target <130/80 mmHg + Diabetes
71
What is the target serum ferritin level when treating anaemia in CKD?
800mcg/L
72
How should hyperkalaemia be treated in CKD?
Withold ACEi, AT1RA, K+ sparing agents
ECG and treat as per protocol
73
What medication class is considered for anaemia when serum ferritin is at the target?
ESA
74
What is the target Hb range when using ESA to correct anaemia?
100-120g/L
75
What medication is used to treat metabolic acidosis? What is the eGFR level for using this medication to treat metabolic acidosis? What is the serum HCO3- level for using this medication to treat metabolic acidosis?
Oral sodium bicarbonate
<30ml/min
<20mmol/L
76
How is osteodystrophy managed in CKD?
Correct calcium, phosphate and vitamin D
Offer bisphosphonates (CI in eGFR <30ml/min)
Offer colecalciferol or ergocalciferol if eGFR >30ml/min
Offer alfacalcidol or calcitriol if eGFR <30ml/min
77
How is hyperparathyroidism treated in CKD?
Treat as per protocol
Consider cinacalcet
Consider parathyroidectomy
78
How is hyperphosphataemia treated in CKD?
Limit dietary phosphate
Offer phosphate binders
79
How is uraemia treated in CKD?
Dialysis & consideration of transplant
Loratadine, menthol & aqueous cream or e45 for itching
80
What process is dialysis based on? What is the goal of dialysis?
Diffusion across a semi-permeable membrane
Restore intracellular and extracellular fluid environment
81
What is the eGFR level where dialysis is usually started? What is a symptom of uraemia that indicate the need for dialysis?
<15ml/min
Anorexia
82
What is a unique characteristic of dialysis patients regarding kidney function? What is not a valid measure in dialysis patients?
Little or no residual kidney function
GFR
83
What dietary changes are required for Haemodialysis patients?
Less fluid intake
Low sodium
Low potassium
Low phosphate
84
What type of access is required for haemodialysis? How is it created? How long does it take for this to be functional? What is another type of vascular access for haemodialysis?
Arteriovenous fistula
Surgically connecting an artery and vein (allows blood at arterial pressure into vein)
~2 months
Central venous access
85
What is a disadvantage of central venous access? How many needles are placed into the vascular access during haemodialysis?
High infection rate
2
86
What does 'dry weight' refer to in haemodialysis? Why is sodium bicarbonate usually not required orally for haemodialysis patients?
Target weight after fluid removal
Administered via dialysis
87
What is added to the blood during dialysis?
Anticoagulant
88
How often is unit based haemodialysis done? How long does unit based haemodialysis last?
3x a week
4 hours
89
How often is home based haemodialysis done? When is home based haemodialysis done?
6x a week
Overnight
90
What is a complication of haemodialysis vascular access? What is a complication of haemodialysis due to anticoagulation? What is a complication of haemodialysis in general?
Occluded access
Bleeding
Sepsis
91
What medication can be used for restless legs? What medication can be used for itching? What topical treatments are used for itch relief?
Clonazepam
Loratadine
Menthol and aqueous cream
92
Why do haemodialysis patients often have lower levels of iron? Why is oral iron therapy not effective for HD patients? What type of iron replacement is usually required for HD patients?
Due to blood loss and inflammation
Poor absorption due to high urea levels
IV
93
When are blood samples taken for HD patients? How often should biochemical and haematological parameters be monitored for HD? How often should biochemical and haematological parameters be monitored for home HD?
During a midweek HD session
Every month in hospitals
At least every 3 months
94
What is the pre-dialysis target blood pressure? What is the post-dialysis target blood pressure?
<140/90
<130/80
95
What is a potential complication post-dialysis? What is the name of the syndrome that is a potential complication when starting HD? What is the cause of this?
Hypotension
Disequilibrium syndrome
Rapid changes in blood composition
96
What is a common symptom of disequilibrium syndrome? How are dialysis sessions adjusted at the start of treatment to prevent disequilibrium syndrome?
Headache
Shorter and more frequent
97
What part of the body acts as a semi-permeable membrane in peritoneal dialysis? Does peritoneal dialysis require fluid or dietary changes? What is the name of the permanent tunnelled catheter used in peritoneal dialysis?
Peritoneum
No fluid or dietary changes
Tenckhoff
98
What does dialysate contain? What is the purpose of this? How long is dialysate left to dwell in the abdomen? How long does the dialysate exchange generally take?
Glucose
Provides osmotic gradient
4-6 hours
About 30 mins
99
What does CAPD stand for? Who is CAPD suited for? How many exchanges are done every day with CAPD? Around how many litres are exchanged per day with CAPD?
Continuous Ambulatory Peritoneal Dialysis
Low transporters
4 exchanges
Around 8-10L
100
What does APD stand for? When is APD usually performed? Who is APD suited for?
How long does APD usually last?
Automated Peritoneal Dialysis
Overnight
Fast transporters
7-10 hours
101
Why should PD bags always be checked? What affects the ability of PD fluid to remove water? What are the three different strengths of PD bags?
Differing strengths and volumes
Amount of glucose
Weak, medium, strong
102
For a 72-year-old female (160cm, 45 kg) with a serum creatinine of 120 µmol/L, what is the next step regarding her Enalapril 5mg OD prescription?
Assess if a dose alteration is needed
103
For a 48-year-old female (165cm, 95 kg, BMI: 35) with a serum creatinine of 100 µmol/L, what action should be taken?
Recommend an appropriate dose of dabigatran
104
For a 55-year-old male (175cm, 70 kg) with a serum creatinine of 80 µmol/L, what is the next step when evaluating him for vancomycin?
Determine if any dose changes are required
105
What formula is recommended for estimating GFR and calculating drug doses in most patients with renal impairment? What patient characteristics are utilized as variables in this formula?
CKD-EPI formula
Serum creatinine, age, sex
106
In the CKD-EPI formula, what does SCr represent? In the CKD-EPI formula, what is the value of K for females? In the CKD-EPI formula, what is the value of K for males? In the CKD-EPI formula, what is the value of α for females? In the CKD-EPI formula, what is the value of α for males?
Serum creatinine in mg/dL
0.7
0.9
-0.329
-0.411
107
What are the causes of CKD?
- Hypertension
- Diabetes Mellitus
- Prolonged/Frequent AKI
- CVD Medication
- Structural defects
- Congenital abnormalities
- Autosomal Dominant Polycystic Kidney Disease (ADPKD)
- Obstructive nephropathy
- Multisystem Diseases
108
How does diabetes contribute to the pathogenicity of CKD? How does hypertension contribute to the pathogenicity of CKD? How does glomerulonephritis contribute to CKD?
Damage to kidney infrastructure
Damages blood vessels in the kidney
Inflammation of the glomeruli
109
Name one class of nephrotoxic drugs that may cause CKD.
NSAIDs
110
What are common signs and symptoms associated with an accumulation of toxins in CKD?
Fatigue
Nausea
Anorexia
Lethargy
Weight Loss
Pruritus
111
What are common signs found in CKD stages 4 and 5?
Hyperkalaemia (impaired excretion)
Uraemia
Anaemia
Impaired Vitamin D Metabolism (reduced hydroxylation of cholecalciferol)
Hyperparathyroidism
Hypocalcaemia
Hyperphosphataemia (impaired excretion)
112
What electrolyte disturbance results from impaired Vitamin D metabolism in CKD? How does CKD lead to metabolic acidosis?
Hypocalcaemia
Less nephron mass to produce bicarbonate
113
At what creatinine clearance level does uraemia usually develop? What is a common cause of uraemia?
<10mL/min
Fluid overload
114
What are the goals of therapy in CKD?
- Prevent or delay the progression of CKD
- Treat underlying causes and contributing factors
- Prevent and/or effectively treat any complications of CKD
- Reduce the patients associated cardiovascular risk
- If needed replace lost kidney function via RRT/ - Transplantation
- In end stage renal disease: Relieve symptoms and improve patients QoL and reduce hospital admissions
115
What are symptoms of uraemia?
- Nausea & Vomiting
- Fatigue
- Anorexia
- Weight loss
- Muscle cramps
- Pruritus
- Change in mental status
116
What are severe complications of untreated uraemia?
- Seizure
- Coma
- Cardiac arrest
- Death
117
Why can spontaneous bleeding occur with severe uraemia?
Due to platelet dysfunction
118
Why are Potassium Sparing Diuretics usually inappropriate in CKD? Why are Thiazide diuretics ineffective at eGFR <30 mL/min?
Increases K+ in CKD
Decreased drug delivery to the kidneys
119
Why should ACE inhibitors be avoided in renal artery stenosis?
May worsen kidney function
120
What is the target blood pressure for CKD patients with low proteinuria (ACR < 70)? What is the target blood pressure for CKD patients with high proteinuria (ACR > 70) or CKD and diabetes?
<140/90
<130/80
121
According to the guidelines, when should an ACE inhibitor/ARB be considered as a first-line agent for hypertension in CKD? What is a suitable 2nd line anti-hypertensive agent if eGFR > 30?
Diabetes or proteinuria
Thiazide-like diuretic or loop diuretic
122
What dose of Atorvastatin should be offered daily for CVD prevention in CKD Stage 3a and onwards?
20mg
123
Why is it important to be aware of the increased risk of bleeding when offering antiplatelet drugs to people with CKD? Why is CKD one of the most common causes of anaemia?
Platelet dysfunction in CKD
Reduced erythropoietin production
124
What are the symptoms of renal anaemia?
Fatigue
Lethargy
SOB
Reduced exercise tolerance
125
Why might phosphate binders contribute to anaemia in CKD?
Reduce dietary iron absorption
126
What investigations should be performed to investigate other causes of anaemia?
1. FBC: WCC, platelets, MCV
2. Haematinics: folate, Vitamin B12
3. Iron studies: ferritin, transferrin, transferrin saturations (TSAT)
4. Parathyroid function (PTH)
5. Inflammatory markers (CRP)
127
When should other causes of anaemia be considered in CKD patients? How do you manage renal anaemia?
1. CrCl >60ml/min
1. Replenish iron stores (oral or IV)
2. Correct EPO deficiency (EPO stimulating agent (ESA))
128
What Hb range should be maintained when managing renal anaemia?
10-12 g/dl
129
What are the cautions with using ESAs? What monitoring is required when using ESAs? What are the MHRA guidelines for ESAs?
HTN, seizures, PRCA
BP, reticulocyte counts, Hb and electrolytes
Observe for severe skin reactions
130
What are the 4 types of Renal Bone Disease - Osteodystrophy?
1. Secondary to hyperparathyroidism
2. Osteomalacia (reduced mineralisation)
3. Mixed osteodystrophy
4. Adynamic bone disease (reduced bone formation and reabsorption)
131
What are the Manifestations of Renal Bone Disease - Osteodystrophy?
Defects of bone mineralization
Bone pain
Fractures
Structural deformities
132
How does decreased GFR lead to hyperphosphatemia in renal bone disease? How does decreased GFR lead to low calcitriol in renal bone disease?
Phosphate retention
Reduced kidney activation of Vitamin D
133
Which condition involves reduced bone mineralisation? Which type of renal bone disease is characterized by reduced bone formation and reabsorption?
Osteomalacia
Adynamic bone disease
134
What are manifestations of renal bone disease?
- Defects of bone mineralisation
- Bone pain
- Fractures
- Structural deformities
135
What happens to the Glomerular Filtration Rate in renal bone disease?
Decreases
136
What happens to phosphate levels in renal bone disease? What happens to calcitriol levels in renal bone disease? What happens to calcium levels in renal bone disease? What happens to phosphate levels in renal bone disease?
Phosphate retention occurs
Calcitriol levels decrease
Hypocalcaemia
Hyperphosphataemia
137
What is skeletal resistance to PTH in renal bone disease?
Bones do not respond to PTH
138
In what stages of CKD does hyperphosphatemia usually occur?
Stage 4-5
139
What is the target phosphate level for adults with stage 4 or 5 CKD who are not on dialysis? What serum phosphate levels should be maintained for adults with stage 5 CKD who are on dialysis?
0.9 and 1.5 mmol/l
1.1 and 1.7 mmol/l (improved removal of phosphate from blood)
140
When should phosphate binders be initiated in CKD? What is the mechanism of action of phosphate binders? When should phosphate binders be taken for maximum efficacy?
Before dialysis, stage 4-5 CKD
Reduce GI absorption of phosphate
Before, with or soon after food
141
What is the purpose of Vitamin D in treating renal bone disease? What does Vitamin D supplementation help to correct? What parameters should be monitored when giving Vitamin D supplements?
Promotes normal physiology and mineral metabolism
Hypocalcaemia and secondary hyperparathyroidism
Serum calcium and phosphate
142
Which Vitamin D supplements are typically used for Stage 1-3 CKD? Which Vitamin D supplements are typically used for Stage 4-5 CKD?
Colecalciferol/Ergocalciferol with calcium
Alfacalcidol or Calcitriol
143
What type of agent is Cinacalcet? For what condition is Cinacalcet licensed?
Calcimimetic agent
Secondary hyperparathyroidism
144
How does Cinacalcet work? What is a significant disadvantage of Cinacalcet?
Suppresses PTH secretion without increasing calcium
Very expensive
145
How long must kidney function or structural abnormality be present to define Chronic Kidney Disease? According to NICE, what two factors define CKD?
Over 3 months
Reduction in kidney function or structural damage
146
According to NICE, what GFR value defines CKD? According to NICE, over what period must a GFR less than 60 ml/min/1.73 m2 be measured to define CKD?
Less than 60 ml/min/1.73 m2
At least 2 occasions, 90 days apart
147
According to KDIGO, what is CKD based on?
Cause, GFR category, and Albuminuria category (CGA)
148
What happens to ammonia synthesis in metabolic acidosis due to kidney disease? What happens to hydrogen ion excretion in metabolic acidosis due to kidney disease?
Kidneys lose the capacity to synthesise ammonia
Kidneys lose the capacity to excrete hydrogen ions
149
What happens to bicarbonate regeneration in metabolic acidosis due to kidney disease?
Kidneys lose the capacity to regenerate bicarbonate
150
What is the normal range of serum bicarbonate? What serum bicarbonate level indicates increased risk of metabolic acidosis?
22-29mmol/l
<21mmol/l
151
When does metabolic acidosis worsen significantly in CKD?
GFR declines below 45 ml/min/1.73 m2
152
In CKD, what blood gas should be checked?
Lactate, base excess, and pH
153
When should oral sodium bicarbonate supplementation be considered?
GFR <30 and bicarbonate <20
154
What are 2 therapies for electrolyte disturbance in CKD? What is a dietary recommendation for electrolyte disturbance in CKD?
Calcium Resonium and Dialysis
Low potassium diet
155
What causes oedema in CKD? What therapies are there for oedema in CKD?
Salt and water retention
Diuretics, fluid restriction, low Na diet
156
What is pruritus in CKD due to? What therapies are there for pruritus in CKD?
Increased phosphate and urea
Anti-histamines, creams, phosphate binders, dialysis
157
Which type of antihistamines are more effective for pruritus?
Sedating antihistamines
158
What therapies are there for leg cramps/restless legs in CKD?
Quinine sulphate, clonazepam
159
What causes gout in CKD? What therapies are there for gout in CKD?
Decreases uric acid secretion
Low dose allopurinol, analgesics
160
Why should metformin be avoided in renal failure with CI <30 mL/min?
Lactic acidosis
161
What are symptoms of CKD?
Hypertension
GI symptoms
162
What drug would you use to counter acidosis?
Sodium bicarbonate
163
When should assessment for renal replacement therapy or conservative management begin? What should be offered to people starting dialysis or conservative management?
At least 1 year before needed
Full dietary assessment by specialist
164
What does haemodialysis manage? How does haemofiltration remove waste? What does haemofiltration remove?
Metabolic disturbances
By convection
Larger solutes/molecules
165
To what is the incidence and prevalence of CKD closely linked?
Ethnic group and socio-economic class
166
What is the cleansing fluid used in peritoneal dialysis called?
Dialysate
167
What dialysis choice should be considered as first choice for children 2 years or under?
Peritoneal dialysis
168
Within what timeframe should adults with progressive deterioration in kidney function be placed on the national transplant list?
Within 6 months of dialysis start
169
What are the benefits of renal transplants? What are the issues with renal transplants
1. No longer need dialysis
Less likely to be hospitalised
2. Supply and "graft-versus" host rejection
170
What are the main class of renal transplant drugs?
ANTI-rejection or immunosuppressive
Anti-infectives
171
Why are anti-infectives normally given during induction of an organ during renal transplant? What antiviral protection is usually given during renal transplant? What anti-infective drug is usually given during induction of an organ in a renal transplant, unless the patient is allergic?
Decrease infection risk
Acyclovir
Co-trimoxazole
172
Name an antifungal medication that a renal transplant patient might receive? What is induction therapy in the context of kidney transplantation? What does induction therapy typically include?
Nystatin
Short-term use of immunosuppressive agents
High doses of corticosteroids
173
How can induction immunosuppressive medications be classified?
Depleting agents
Non-depleting agents
174
What is the categorization of induction immunosuppressive medications based on? What is a characteristic of depleting agents?
When are depleting agents also used?
Ability to target specific antigens
Potent with potential for toxicity
Severe cases of acute rejection
175
How is Rabbit anti-human thymocyte immunoglobulin (Thymoglobuline) made? What do the antibodies in r-ATG attach to? What is the typical dose of r-ATG administered after a kidney transplant?
Injecting human thymus cells into rabbits
Cells of the immune system
1 to 1.5 mg/kg/day
176
What is the range of days that r-ATG is administered for after a kidney transplant? What is the cumulative dose of r-ATG that is administered after a kidney transplant? How many mg does r-ATG come in per vial?
3-9 days
3-13.5mg/kg
25mg
177
What is a phenomenon associated with patients treated with rATG?
Cytokine release syndrome
178
What type of antibody is basiliximab? What is the mechanism of action of basiliximab? What is basiliximab authorized for in the UK? What is the dosage of basiliximab administered? When are the doses of basiliximab administered?
Monoclonal
Interleukin-2 receptor antagonist
Prophylaxis of acute organ rejection
2 doses of 20mg dose
2 hours before, 4 days after surgery
179
What is tacrolimus? Why is maintenance on one brand of tacrolimus paramount? What is belatacept? What does belatacept inhibit?
Calcineurin inhibitor
Differing bioavailability between formulations
Soluble fusion protein
CD28-mediated co-stimulation of T-cells
180
What can Belatacept be used in combination with?
Mycophenolate and/or corticosteroids
181
What is Mycophenolate mofetil used for? What forms does Mycophenolate mofetil come in?
Prophylaxis of acute transplant rejection
Capsules or an oral suspension
182
What type of inhibitor is Mycophenolate sodium? What enzyme does Mycophenolate sodium inhibit? What pathway does Mycophenolate sodium inhibit?
Reversible inhibitor
Inosine monophosphate dehydrogenase
De novo pathway of guanosine nucleotide synthesis
183
What is creatinine a by-product of?
Muscle breakdown
184
What patient groups is the Cockcroft – Gault Equation commonly used for?
- Direct-acting oral anticoagulants (DOACs)
- Patients taking nephrotoxic drugs
- Elderly patients (aged 75 years and older)
- Patients at extremes of muscle mass (BMI <18 kg/m2 or >40 kg/m2)
- Patients taking medicines that are largely renally excreted and have a narrow therapeutic index, such as digoxin and sotalol
