CPGS Flashcards
2021 Exam CPGs: DM, Lepto, KT and Donor
Start of monitoring of Ca, phosphate, PTH, Alkphos
CKD G3a
interval of monitoring of Ca and Phos
G3: q6-12
G4 q3-6
G5 Q1-3
PTH interval monitoring
G3 baseline
G4: q6-12 months
G5 - q3-6 months
gold standard for the diagnosis and classification of renal osteodystrophy
bone biopsy
when to do bone biopsy
unexplained fractures, refractory hypercalcemia, suspicion of osteomalacia, atypical response to standard therapies for elevated PTH, progressive decreases in BMD despite standard therapy
dialysate calcium should be
1.25-1.50 mmol/L
PTH should be maintained in
2-9x of upper normal limit for the assay
severe hyperparathyroidism failing to respond to medical
parathyroidectomy
immediate post KT Ca and phos monitoring
weekly until stable
when to reduce dose or discontinue ACEi/ARBs
symptomatic hypotension or uncontrolled hyperkalemia
Physical activity for DM
moderate intensity for at least 150 mins per week
First line therapy for Type 2 DM and CKD
Metformin and SGLT2
Weight loss, HF, high risk ASCVD
(Dm meds effect)
GL1P-RA
Potent glucose lowering drug
(2)
GL1P-RA, insulin
avoid hypoglycemia
(4 drug)
GL1P
DPP4
TZD
AGI
Low cost
SU, TZD, aGI
EGFR < 15 or with HD
DPP4, insulin TZD
When to adjust dose of Metformin
EGFR < 45-59
evaluation for KT should be done
at least 6-12 months before anticipated dialysis
when to not recommend transplant
multiple myeloma unless curative tx and in remission;
AL amyloidosis with extrarenal involvement, decompensated cirrhosis; severe irreversible lung disease; uncorrectable and symptomatic cardiac disease; central neurodegenerative disease
Delay transplant evaluation until properly managed
unstable psych, substance disorder, ongoing health compromising nonadherent behavior, active infection, malignancy, cardiac disease, peripheral arterial disease; recent stroke, gi disease, hepatitis; severe hpt
exception of infection that may proceed with transplant evaluation
hepatitis C
exception in malignancies that can proceed with transplantation
low grade - prostate cancer (gleason score < 6) and renal tumors (<1 cm)
pre-emptive transplantation with a living kidney donor as preferred treatment for transplant eligible CKD patients who
eGFR < 10 ml/min or earlier with symptoms; EgFR < 15 ml/min for children
abstain from tobacco use at a minimum of ___ prior to waitlisting or living donor
1 month
screening for current or former heavy tobacco smokers (>= 30 pack years)
chest CT scan
antiplatelets except aspirin should be stopped ____ days prior to living donor transplantation
5 days
contraindication to transplant in terms of anticoagulation
on direct acting oral anticoagulants (apixaban, rivaroxaban)
management for symptomatic PCKD (pain, infection, malignancy, insufficient room for transplant)
staged or simultaneous native nephrectomy
primary hyperoxaluria type 1
combined or sequential liver-kidney transplantation
strategies to lower total body oxalate burden
intensive dialysis
diet modification and pyridoxine treatment
HCV and compensated cirrhosis (without portal hypertension)
isolated kidney transplantation
HCV and decompensated cirrhosis
combined liver-kidney transplantation and deferring HCV treatment until after transplantation
monitoring of hbsag and hbv dna post transplant for hbsag negative, anti-hbc positive patients for
min of 1 year
vaccination for varicella and MMR for seronegative candidates should be done
at least 4 weeks prior to transplantation
live vaccines
MMR, VZV, shingles, yellow fever, oral typhoid, polio
splenectomized patients
pneumococcal, hemophilus and meningococcal vaccination
screening for bladder cancer
high level cyclophosphamide, heavy smoking of 30 pack years
screening for bladder ca
cystoscopy
screening for hcc
ultrasound, a-fetoprotein
no waiting time for candidates with surgically curatively treated
nonmetastatic basal cell ca melanoma in situ small renal cell Ca < 3 cm prostate Ca gleason score < 6 carcinoma in situ (ductal, cervical) thyroid ca, follicular, papillarry < 3 cm superficial bladder cancer
acute leukemia and high grade lymphoma
avoid transplant unless curative and remission and cancer free
noninvasive CAD screening
asymptomatic candidates at high risk for CAD (DM, previous CAD) with poor functional capacity
asymptomatic advanced triple vessel coronary disease
excluded
asymptomatic candidates on dialysis for at least 2 years, risk factors for pulmonary hypertension
2d echo
cut off for pulmonary artery systolic pressure
> 45 or > 60 (R heart catheterization)
exclude from transplant
uncorrectable CLass 3/4, severe CAD, EF < 30%, severe valvular disease
cardiac amyloidosis
exclude
clinically apparent PAD + abnormal noninvasive testing or prior vascular procedure
noncontrast CT imaging of the abdomen/pelvis
at least ____ after a stroke or after a TIA before a KT
6 months after stroke
3 months after TIA
screen candidates with ADPKD disease for
intracranial aneurysms (high risk)
if symptoms suggestive of PUD
EGD and Hpylori testing
acute pancreatitis, should delay KT
minimum of 3 months after symptoms have resolved
major complications of leptospiroris, marker of severity and indication for hospitalization
AKI (poorer prognosis)
Features of leptospirosis associated AKI
sterile pyuria, tea colored urine, mild proteinuria to severe anuric acute renal failure, nonoliguric renal failure with mild hypokalemia, oliguria with hyperkalemia (severity of AKI)
oliguria with hyperkalemia
poor prognosis
pathology of leptospirosis associated AKI
acute tubular damage and tubulointerstitial nephritis
lab findings associated with increase ind eath
neutrophilia and thrombocytopenia
predictors of mortality in severe leptospirosis
crea > 3, age > 40, oliguria, platelet < 70k and pulmonary involvement
Tubular dysfunction
hyponatremia and hypokalemia
responsible for non-oliguria
vasopressin resistance
urine output < 0.5 ml/kg/hr or M 400 ml/day or report decrease or no urine output with the last 12 hours
oligura
predictors of oliguria
> 40 years, crackles, low arterial pH, hyponatremia, increased crea, elevated DB and AST, low platelet and low alkphos
recommended map in leptospirosis
65-70 mmhg
initial fluid resuscitation in shock
ballanced crystalloids
If K is in the high normal value or with hyperkalemia
isotonic saline
initial rate
20 ml/kg.hr or 500 ml within 15-30 minutes
indications for acute rrt
uremic symptoms; pH <7.2, fluid overload, oliguria despite adequate hydration, crea > 3, K > 5 in an oliguric patient, ARDS, pulmo hemorrhage
frequency of dialysis in leptospirosis
daily dialysis
hemodynamically unstable dialysis modality
CRRT
indications for pulse therapy
AKI plus one of the ff: platelet < 100k, MAP < 65, inotropes, ards, prolonged PT/PTT
dose of pulse therapy
3 doses of MPPT 500 mg+ 1 dose of cyclophosphamide 60 mk IV
Donors should stop smoking
at least 4 weeks before donation and life long abstinence
evaluation of GFR
serum creatinine
confirmation of GFR
measured GFR using inulin
measured CrCl
eGFR using crea and cystatin C
repeated estimated GFR from serum crea
acceptable GFR
> 90 ml/min
GFR that should not donate
GFR < 60 ml/min
acceptable AER
< 30 mg/day
AER that should not donate
> 100 mg/day
IgA nephropathy
do not donate
evaluation for persistent microscopic hematuria
urinalysis and urine CS; cystoscopy and imaging, 24h urine stone panel, kidney biopsy
elevated FBS, gestational DM or family history of DM in a first degree relative
2h OGTT or Hba1c
repeat testing of HIV, HBC and HCV
within 28 days
Genetic kidney disease that can cause kidney failure and APKD; pregnant
do not donate
