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CCTs Year 3 > CKD > Flashcards

CKD Flashcards

1
Q

What test is used to differentiate between IBS and IBD?

A

Faecal calprotectin - a marker for bowel inflammation

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2
Q

Criteria to diagnose AKI

A
  • creatinine raise of 26 micromol/L or more within 48hours
  • 50% of raise in creatinine occurred/presumed within 7 days
  • decreased urine output to <0.5 ml/kg/hr
  • in children: decrease of 25% in eGFR within 7 days
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3
Q

What’s ACR?

What is it used for?

A

ACR = albumin: creatinine ratio

used to classify CKD

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4
Q

What are the two biggest caused of CKD?

A
  • hypertension
  • diabetes
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5
Q

Diagnosis of CKD

  • what and for how long
A

Reduction of eGFR measured 3 months apart

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6
Q

What’s ‘end stage’ CKD

A

eGFR <15 -> requiring dialysis, kidney transplant

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7
Q

Nephrotoxic drugs

(intrarenal cause of CKD)

A
  • Lithium
  • NSAIDs
  • steroids
  • methotrexate
  • rifampicin
  • Penicillin
  • gentamycin
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8
Q

Two types of drugs that we need to check renal function after administration

A
  • ACE inhibitors (influences glomerular hydrodynamics)
  • anticholinergics (e.g. TCAs) -> as they may cause urinary retention
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9
Q

What is an alternative for NSAIDs in kidney disease

A
  • Paracetamol
  • co-codamol
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10
Q

Decreased eGFR - what do we need to consider (in terms of other drugs)?

A

drug review -> as some drugs’ doses need to be reduced

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11
Q

What effects do ACE inhibitors have on the kidney?

A

A. Renoprotective (especially if hypertension)

B. Potential for kidney failure if a person has bilateral renal stenosis - so need to monitor kidney function after introduction

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12
Q

What to do when we introduce ACE inhibitors?

A
  1. Do baseline eGFR and U&Es levels
  2. repeat in 7-10 days *

*if decreased renal function - potential underlying bi-lateral renal stenosis

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13
Q

What BP do we aim for in a diabetic person?

A

130/80 or less

* this is due to an already occurring disease that may contribute to CVS/renal and other organ damage

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14
Q

What vaccines should be offered and at what age for people with CKD?

A

Irrespective of age:

  • flu jab -> once a year
  • pneumococcal vaccine -> every 5 years
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15
Q

Do we need to refer a person with T2DM to an endocrinologist?

A

No - we can manage it at primary care

*unless difficult to manage

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16
Q

When do we refer a person with CKD to a nephrologist?

A
  • progressive deterioration
  • the decrease in eGFR 25% or more in 12 months
  • sudden drop in short space of time
  • eGFR <30
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17
Q

In what instances would we consider stopping ACE inhibitors (after their introduction)?

A
  • drop in eGFR >25% from pre-Rx/baseline levels
  • rise in creatinine >30%
  • K+ levels > 6.0

*if parameters had decreased (but not enough to stop ACEinhibitors) -> repeat tests (U&Es and eGFR) in 2 weeks + compare with baseline

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18
Q

What medication we can use to replace ACE inhibitors with (in case they will cause renal #)?

A
  • alpha blocker

or

  • CCB

or

  • beta blocker
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19
Q

Can we replace ACE inhibitor (in case of renal #) with Losartan?

A

No, as Losartan has the same mechanism as ACE inhibitors

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20
Q

When to refer to the nephrology team? (in CKD)

A
  • Poorly controlled BP ( and patient on 4 drugs)
  • CKD 4-5
  • progressive decline >25% within 12 months
  • persistant proteinuria
  • bi-lateral renal stenosis
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21
Q

Introduction of what drug do we need to consider in pt with CKD in terms of the risks?

A

CVS risks -> give statins

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22
Q

What are the components of tests for CKD?

A
  • creatinine
  • eGFR
  • albumin - creatinine ratio (ACR)
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23
Q

what is the principle behind albumin: creatinine ratio?

A

Normally, albumin is filtered back into the bloodstream (by the kidneys)

  • if kidney are #, then more albumin will be present in the urine -> this is microalbuminuria test
  • ACR -> comparing the creatinine to albumin in a sample -> allows to compensate for variations of urine concentration in ‘spot’ samples*

* i.e. we can say that there is microalbuminuria only when ACR is within certain ranges

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24
Q

When a female and a male patient is said to have microalbuminuria?

A

microalbuminuria is defined as

Female: ACR ≥3.5 mg/mmol

Male: ≥2.5 mg/mmol

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25
Q

Who should be offered tests for CKD?

A
  • diabetes
  • hypertension
  • CVS disease (cerebrovascular disease, MI, peripheral vascular disease, ischaemic heart disease, chronic heart failure)
  • structural renal tract disease: recurrent renal calculi or prostatic hypertrophy
  • people with systemic diseases that may affect kidney (e.g. SLE)
  • AKI
  • opportunistic detection of haematuria
  • people with relatives of end-stage CKD, genetic predisposition
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26
Q

What risks factors should not be taken into consideration if we consider testing for CKD?

A
  • obesity alone (unless metabolic syndrome, diabetes or hypertension)
  • gender, ethnicity, age
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27
Q

Monitoring eGFR in people on certain nephrotoxic drugs

  • how often
  • what drugs
A
  • at least annually
  • NSAIDs, Lithium, calcineurin inhibitors (cyclosporin or tacrolimus)*
  • *calcineurin inhibitors* -> immunomodulating agents (to reduce inflammation) e.g. organ transplant, skin disorders, UC
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28
Q

How do we usually test for haematuria

A

Urine dipstick -> if 1+ or more positive -> evaluate further (e.g. microscopic urine analysis)

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29
Q

What results will differentiate persistent vs transient haematuria in the absence of proteinuria?

A

2 out of 3 positive strip tests would confirm persistent invisible haematuria

30
Q

What diagnosis should we consider in persistent invisible haematuria (with or without proteinuria)?

A

urinary tract malignancy (in appropriate age group)

31
Q

How should be a patient with persistent invisible haematuria (in absence of proteinuria) followed up?

A

Annual repeat testing:

  • haematuria
  • proteinuria
  • albuminuria
  • eGFR
  • BP

*for as long as haematuria persist

32
Q

What’ s the aim for (systolic and diastolic) BP in people with CKD?

A

Systolic: 140 mmHg

Diastolic: 90 mmHg

33
Q

What’ s the aim for (systolic and diastolic) BP in people with CKD and diabetes?

A

systolic below 130 mmHg

diastolic below 80 mmHg

34
Q

Low - cost renin-angiotensin (RAAS) system antagonist should be offered to people with CKD and…

A
  • diabetes and ACR of 3mg/mmol or more
  • hypertension and ACR of 30 mg/mmol or more
  • ACR of 70 mg/mmol or more (irrespective of CVS disease or hypertension)
35
Q

A. How to manage the risks of CVS in people with CKD?

B. when to increase the dose?

A

A. Offer _*Atorvastatin* 20mg_ -> primary and secondary prevention of CVS in CKD

B. Increase the dose if:

  • >40% reduction in non-HDL has not been achieved
  • eGFR is 30 ml/min/1.74m2 or more

*if eGFR is less than 30 ml/min/1.74m2 -> consult the use of higher dose with a renal specialist

36
Q

CKD stages - table

A
37
Q

Complications of CKD (other than CVS) + when an how to check for them

A
  • anaemia - check haemoglobin level in people with GFR less than 45 ml/min/1.73m2
  • bone conditions - if eGFR of 30ml/min/1.73m2 or more - do not routinely measure calcium, phosphate, PTH and vit D levels -> otherwise patients at lower categories should be under the care of a nephrologist and may need calcium/ vitamin D supplements, low phosphate diet and sodium bicarbonate (to prevent metabolic acidosis)
38
Q

What may suggest that a person with CKD may be at higher risk of progression into end-stage kidney disease/ accelerated progression of CKD?

A
  • 25% or more decrease in GFR category within 12 months

or

  • decrease in eGFR of 15ml / min/ 1.73 m2 per year
39
Q

How to identify the rate of CKD progression?

A

Obtain a minimum of 3 eGFR readings in a period of no more than 90 days

40
Q

What further testing to do if there is a new finding of reduced eGFR in a person with established CKD?

A

repeat eGFR within 2 weeks -> to exclude causes of acute deterioration of GFR

41
Q
A
42
Q

For how long do we monitor a person after AKI?

A

2-3 years after AKI

*even if serum creatinine has returned to baseline-> this is because patients with AKI are at increased risk of developing CKD

43
Q

Why NSAIDs may increase risk of kidney #?

A

NSAIDs will inhibit prostaglandins -> afferent arteriole constriction -> kidney underperfusion

44
Q

Can we combine ACE inhibitors and NSAIDs?

A

Not - as both of them would cause acute AKI

(ACE inhibitors -> renal artery stenosis; NSAIDs -> afferent arteriole constriction)

45
Q

Which drugs and why may cause kidney # in case of biochemical;/ electrolyte changes?

A
  • Increased Potassium-> K+ supplements, K+ diuretics, Ispaghula husk
  • High sodium content -> antiacids
  • Excessive vitamin D replacement -> alphacalcidol
46
Q

What drugs may cause crystalluria (crystals found in the urine) and therefore obstruction?

A
  • sulphonamides
  • acetazolamide
  • methotrexate
47
Q

What drugs have the potential to cause glomerular damage?

A
  • penicillamine
  • gold
  • aptopril
  • phenytoin
  • penicillins
  • sulphonamides
  • rifampicin
48
Q

What drugs have the potential to cause interstitial nephritis?

A
  • penicillins
  • cephalosporins
  • sulphonamides
  • thiazide diuretics
  • furosemide
  • NSAIDs
  • rifampicin
49
Q

What drugs have the potential to cause Acute Tubular Necrosis?

A

Drugs that cause direct toxicity to the renal tubules:

  • aminoglycosides
  • amphotericin*
  • ciclosporin

*amphotericin - anti-fungal med

50
Q

What drugs may cause analgesic nephropathy?

A

paracetamol and/or aspirin combinations

It is reversible

51
Q

What drug can cause nephrogenic diabetes insipidus?

A

Lithium

52
Q

In general (classes), what drugs to be careful about in CKD?

A
  • antibiotics
  • H2 receptor antagonists
  • Digoxin
  • anti-convulsants
  • NSAIDs
53
Q

General principles in prescribing in renal impairment

A
  • avoid nephrotoxic drugs (when possible)
  • dose adjustment for CKD - depending on the stage

* dialysis can remove some drugs

* dose adjustment done either by:

a) size of an individual dose is reduced
b) increased interval between doses

54
Q
A
55
Q

RAAS - pathway (physiology)

A
56
Q

Vitamin D pathway (physiology)

A
57
Q

EPO production in the kidney (negative feedback mechanism- physiology)

A
58
Q

What does ACR detect?

A

Proteinuria

*it is more sensitive than urinalysis

59
Q

Normal eGFR and increased ACR - is patient at risk of CVS?

A

Yes

60
Q

True or false

1. CKD can be diagnosed on 2 eGFR results taken one month apart

2. Abnormal levels of proteinuria for ≥3 months, with or without a decrease in GFR, is diagnostic of chronic kidney disease

A
  1. False -> at least 3 months apart needed for Dx of CKD
  2. True (look at categories in terms of ACR as well)
61
Q

True or false

1. Urine dipstick testing can be reliably used to detect microalbuminuria

2. After Acute Kidney Injury (AKI) people are at 4-fold greater risk of developing CKD, even if their renal function completely normalizes.

A

1. False -> various urine dipstick may be more or less sensitive (most may not detect microalbuminuria)

2. True - should monitor kidney function for 2-3 years

62
Q

True or false

If a CKD patient’s K rises from 4.5 to 5.5 after starting Ramipril you should always stop the drug.

A

False - Stop ACE if rises to ≥6 (Don’t start ACE if initial K is>5)

63
Q

True or false

If a CKD patient’s eGFR drops from 60 to 44 after starting Ramipril you should always stop the drug.

A

True – Stop if eGFR falls by more than 25% of pre-treatment level

In that case, there is a fall of 16=26% of 60

64
Q

True or false

A patient with normal eGFR and severe proteinuria may be at higher risk of progression than a patient with reduced eGFR but no proteinuria

A

True – Significant proteinuria is a high risk for progression

65
Q

True or false

All patients with CKD4 should be referred to Nephrology

A

True - patients with CKD4 should be referred (according to NICE guidelines)

66
Q

What to do if a patient is <40 years old, has URTIs symptoms and cola-coloured urine?

A

Refer to nephrologist (likely to have acute glomerulonephritis)

  • some patients <40 yrs with cola-coloured urine and an inter-current (usually upper respiratory tract) infection will have an acute glomerulonephritis
67
Q

Urological referral for further investigations should be considered in

A

Urological referral for further investigations:

  • all patients with macroscopic haematuria (any age)
  • all patients with symptomatic non-visible haematuria
  • all patients with asymptomatic non-visible haematuria at age of 40 or >40
68
Q

When is a nephrological referral needed?

A

Nephrological referral for the patients:

  • who have had a urological cause excluded
  • have not met the referral criteria for a urological assessment

*need for a nephrology referral in this situation depends on factors other than simply the presence of haematuria

  • nephrology referral is recommended if there is concurrent factor (mentioned on another flashcard)
69
Q

A concurrent factors (apart from haematuria) that will prompt nephrology referral

A
  • proteinuria (ACR ≥30mg/mmol)
  • isolated haematuria (in the absence of significant proteinuria) + hypertension (in those aged <40)
  • visible haematuria that happens with an infection (e.g. URTI)
70
Q

2 weeks bladder cancer pathway referral criteria

A

An appointment within 2 weeks for bladder cancer:

  • aged 45 and over and have:
    • unexplained visible haematuria without urinary tract infection or
    • visible haematuria that persists or recurs after successful treatment of urinary tract infection, or
  • aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test

CCTs Year 3 (14 decks)

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